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Kataoka Y, Kitahara S, Funabashi S, Makino H, Matsubara M, Matsuo M, Omura-Ohata Y, Koezuka R, Tochiya M, Tamanaha T, Tomita T, Honda-Kohmo K, Noguchi M, Murai K, Sawada K, Iwai T, Matama H, Honda S, Fujino M, Nakao K, Yoneda S, Takagi K, Otsuka F, Asaumi Y, Hosoda K, Nicholls SJ, Yasuda S, Noguchi T. Glucagon-like Peptide-1 analogues and delipidation of coronary atheroma in statin-treated type 2 diabetic patients with coronary artery disease: The prespecified sub-analysis of the OPTIMAL randomized clinical trial. Atheroscler Plus 2024; 56:1-6. [PMID: 38617596 PMCID: PMC11015340 DOI: 10.1016/j.athplu.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/26/2024] [Accepted: 03/13/2024] [Indexed: 04/16/2024]
Abstract
Background and aims Randomized clinical trials have demonstrated the ability of glucagon-like peptide-1 analogues (GLP-1RAs) to reduce atherosclerotic cardiovascular disease events in patients with type 2 diabetes (T2D). How GLP-1RAs modulate diabetic atherosclerosis remains to be determined yet. Methods The OPTIMAL study was a prospective randomized controlled study to compare the efficacy of 48-week continuous glucose monitoring- and HbA1c-guided glycemic control on near infrared spectroscopty (NIRS)/intravascular ultrasound (IVUS)-derived plaque measures in 94 statin-treated patients with T2D (jRCT1052180152, UMIN000036721). Of these, 78 patients with evaluable serial NIRS/IVUS images were analyzed to compare plaque measures between those treated with (n = 16) and without GLP-1RAs (n = 72). Results All patients received a statin, and on-treatment LDL-C levels were similar between the groups (66.9 ± 11.6 vs. 68.1 ± 23.2 mg/dL, p = 0.84). Patients receiving GLP-1RAs demonstrated a greater reduction of HbA1c [-1.0 (-1.4 to -0.5) vs. -0.4 (-0.6 to -0.2)%, p = 0.02] and were less likely to demonstrate a glucose level >180 mg/dL [-7.5 (-14.9 to -0.1) vs. 1.1 (-2.0 - 4.2)%, p = 0.04], accompanied by a significant decrease in remnant cholesterol levels [-3.8 (-6.3 to -1.3) vs. -0.1 (-0.8 - 1.1)mg/dL, p = 0.008]. On NIRS/IVUS imaging analysis, the change in percent atheroma volume did not differ between the groups (-0.9 ± 0.25 vs. -0.2 ± 0.2%, p = 0.23). However, GLP-1RA treated patients demonstrated a greater frequency of maxLCBI4mm regression (85.6 ± 0.1 vs. 42.0 ± 0.6%, p = 0.01). Multivariate analysis demonstrated that the GLP-1RA use was independently associated with maxLCBI4mm regression (odds ratio = 4.41, 95%CI = 1.19-16.30, p = 0.02). Conclusions In statin-treated patients with T2D and CAD, GLP-1RAs produced favourable changes in lipidic plaque materials, consistent with its stabilization.
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Affiliation(s)
- Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Satoshi Kitahara
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
- Department of Cardiovascular Medicine, Kashiwa Kousei General Hospital, Kashiwa, Japan
| | - Sayaka Funabashi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
- Department of Cardiovascular Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Hisashi Makino
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Masaki Matsubara
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Miki Matsuo
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Yoko Omura-Ohata
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Ryo Koezuka
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Mayu Tochiya
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Tamiko Tamanaha
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Tsutomu Tomita
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Kyoko Honda-Kohmo
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Michio Noguchi
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Kota Murai
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Kenichiro Sawada
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Takamasa Iwai
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Hideo Matama
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Masashi Fujino
- Victorian Heart Institute, Monash University, Melbourne, Australia
| | - Kazuhiro Nakao
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Shuichi Yoneda
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Kensuke Takagi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Kiminori Hosoda
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
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2
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Nissen SE, Wolski K, Watts GF, Koren MJ, Fok H, Nicholls SJ, Rider DA, Cho L, Romano S, Melgaard C, Rambaran C. Single Ascending and Multiple-Dose Trial of Zerlasiran, a Short Interfering RNA Targeting Lipoprotein(a): A Randomized Clinical Trial. JAMA 2024; 331:1534-1543. [PMID: 38587822 PMCID: PMC11002768 DOI: 10.1001/jama.2024.4504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/06/2024] [Indexed: 04/09/2024]
Abstract
Importance Lipoprotein(a) is a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and calcific aortic stenosis, with no pharmacological treatments approved by regulatory authorities. Objectives To assess the safety and tolerability of zerlasiran, a short interfering RNA targeting hepatic synthesis of apolipoprotein(a), and effects on serum concentrations of lipoprotein(a). Design, Setting, and Participants Single- and multiple-dose study in healthy participants and patients with stable ASCVD, respectively, with lipoprotein(a) serum concentrations greater than 150 nmol/L, conducted at 7 research sites in the US, the Netherlands, UK, and Australia between November 18, 2020, and February 8, 2023, with last follow-up on August 23, 2023. Interventions Participants were randomized to receive (1) a single subcutaneous dose of placebo (n = 8), zerlasiran 300 mg (n = 6) or 600 mg (n = 6); or (2) 2 doses of placebo (n = 9), zerlasiran 200 mg (n = 9) at a 4-week interval or 300 mg (n = 9) or 450 mg (n = 9) at an 8-week interval. Main Outcomes Measures The primary outcome was safety and tolerability. Secondary outcomes included serum levels of zerlasiran and effects on lipoprotein(a) serum concentrations. Results Among 37 patients in the multiple-dose group (mean age, 56 [SD, 10.4] years; 15 [42%] women), 36 completed the trial. Among 14 participants with extended follow-up after single doses, 13 completed the trial. There were no serious adverse events. Median baseline lipoprotein(a) concentrations in the multiple-dose group were 288 (IQR, 199-352) nmol/L. Median changes in lipoprotein(a) concentration at 365 days after single doses were 14% (IQR, 13% to 15%) for the placebo group, -30% (IQR, -51% to -18%) for the 300 mg of zerlasiran group, and -29% (IQR, -39% to -7%) for the 600-mg dose group. After 2 doses, maximal median changes in lipoprotein(a) concentration were 19 (IQR, -17 to 28) nmol/L for the placebo group, -258 (IQR, -289 to -188) nmol/L for the 200 mg of zerlasiran group, -310 (IQR, -368 to -274) nmol/L for the 300-mg dose group, and -242 (IQR, -343 to -182) nmol/L for the 450-mg dose group, with maximal median percent change of 7% (IQR, -4% to 21%), -97% (IQR, -98% to -95%), -98% (IQR, -99% to -97%), and -99% (IQR, -99% to -98%), respectively, attenuating to 0.3% (IQR, -2% to 21%), -60% (IQR, -71% to -40%), -90% (IQR, -91% to -74%), and -89% (IQR, -91% to -76%) 201 days after administration. Conclusions Zerlasiran was well tolerated and reduced lipoprotein(a) concentrations with infrequent administration. Trial Registration ClinicalTrials.gov Identifier: NCT04606602.
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Affiliation(s)
| | - Kathy Wolski
- Cleveland Clinic Center for Clinical Research, Cleveland, Ohio
| | - Gerald F. Watts
- Department of Cardiology, Royal Perth Hospital and School of Medicine, University of Western Australia, Perth, Australia
| | - Michael J. Koren
- Jacksonville Center for Clinical Research, Jacksonville, Florida
| | - Henry Fok
- Silence Therapeutics, London, United Kingdom
| | | | | | - Leslie Cho
- Cleveland Clinic Center for Clinical Research, Cleveland, Ohio
| | | | - Carrie Melgaard
- Cleveland Clinic Center for Clinical Research, Cleveland, Ohio
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Nicholls SJ. Integrating lipoprotein(a) into preventive cardiology: probably important to get the measurement right. Eur J Prev Cardiol 2024; 31:901-902. [PMID: 38296811 DOI: 10.1093/eurjpc/zwae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 01/27/2024] [Indexed: 02/02/2024]
Affiliation(s)
- Stephen J Nicholls
- Victorian Heart Institute, Monash University, 631 Blackburn Road, Melbourne, VIC 3168, Australia
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4
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Nicholls SJ, Nelson AJ, Ditmarsch M, Kastelein JJP, Ballantyne CM, Ray KK, Navar AM, Nissen SE, Golberg AC, Brunham LR, Curcio D, Wuerdeman E, Neild A, Kling D, Hsieh A, Dicklin MR, Ference BA, Laufs U, Banach M, Mehran R, Catapano AL, Davidson MH. Obicetrapib on Top of Maximally Tolerated Lipid-Modifying Therapies in Participants With or at High Risk for Atherosclerotic Cardiovascular Disease: Rationale and Designs of BROADWAY and BROOKLYN. Am Heart J 2024:S0002-8703(24)00116-9. [PMID: 38705341 DOI: 10.1016/j.ahj.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 05/07/2024]
Abstract
Obicetrapib, a novel, selective cholesteryl ester transfer protein (CETP) inhibitor, reduces low-density lipoprotein cholesterol (LDL-C), LDL particles, apolipoprotein (Apo) B, and lipoprotein(a) [Lp(a)] and increases high-density lipoprotein cholesterol (HDL-C) when added to statins with or without ezetimibe. By substantially reducing LDL-C, obicetrapib has the potential to lower atherogenic lipoproteins in patients with atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial hypercholesterolemia (HeFH) whose LDL-C levels remain high despite treatment with available maximally tolerated lipid-modifying therapies, addressing an unmet medical need in a patient population at high risk for cardiovascular events. BROADWAY (NCT05142722) and BROOKLYN (NCT05425745) are ongoing placebo-controlled, double-blind, randomized Phase III trials designed to examine the efficacy, safety, and tolerability of obicetrapib as an adjunct to dietary intervention and maximally tolerated lipid-modifying therapies in participants with a history of ASCVD and/or underlying HeFH whose LDL-C is not adequately controlled. The primary efficacy endpoint was the percent change in LDL-C from baseline to day 84. Other endpoints included changes in Apo B, non-HDL-C, HDL-C, Apo A1, Lp(a) and triglycerides in addition to parameters evaluating safety, tolerability, and pharmacokinetics. BROADWAY also included an adjudicated assessment of major adverse cardiovascular events, measurements of glucose homeostasis, and an ambulatory blood pressure monitoring substudy. A total of 2532 participants were randomized in BROADWAY and 354 in BROOKLYN to receive obicetrapib 10 mg or placebo (2:1) for 365 days with follow-up through 35 days after the last dose. Results from both trials are anticipated in 2024. These trials will provide safety and efficacy data to support the potential use of obicetrapib among patients with ASCVD or HeFH with elevated LDL-C for whom existing therapies are not sufficiently effective or well-tolerated.
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Affiliation(s)
| | - Adam J Nelson
- Victorian Heart Institute, Monash University, Victoria, Australia
| | | | | | | | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Ann Marie Navar
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven E Nissen
- Cleveland Clinic Lerner School of Medicine at Case Western Reserve University, Cleveland, OH, USA
| | - Anne C Golberg
- Washington University School of Medicine, St. Louis, MO, USA
| | - Liam R Brunham
- UBC Centre for Heart Lung Innovation, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Annie Neild
- NewAmsterdam Pharma, Naarden, The Netherlands
| | | | | | | | - Brian A Ference
- Centre for Naturally Randomized Trials, University of Cambridge, Cambridge, UK
| | - Ulrich Laufs
- Klinik und Poliklinkk für Kardiologie, Leipzig University, Germany
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidologym, Medical University of Lodz (MUL), Lodz, Poland
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alberico L Catapano
- IRCCS MultiMedica, Milan, Italy; Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
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5
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Gibson CM, Duffy D, Korjian S, Bahit MC, Chi G, Alexander JH, Lincoff AM, Heise M, Tricoci P, Deckelbaum LI, Mears SJ, Nicolau JC, Lopes RD, Merkely B, Lewis BS, Cornel JH, Trebacz J, Parkhomenko A, Libby P, Sacks FM, Povsic TJ, Bonaca M, Goodman SG, Bhatt DL, Tendera M, Steg PG, Ridker PM, Aylward P, Kastelein JJP, Bode C, Mahaffey KW, Nicholls SJ, Pocock SJ, Mehran R, Harrington RA. Apolipoprotein A1 Infusions and Cardiovascular Outcomes after Acute Myocardial Infarction. N Engl J Med 2024; 390:1560-1571. [PMID: 38587254 DOI: 10.1056/nejmoa2400969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Cardiovascular events frequently recur after acute myocardial infarction, and low cholesterol efflux - a process mediated by apolipoprotein A1, which is the main protein in high-density lipoprotein - has been associated with an increased risk of cardiovascular events. CSL112 is human apolipoprotein A1 derived from plasma that increases cholesterol efflux capacity. Whether infusions of CSL112 can reduce the risk of recurrent cardiovascular events after acute myocardial infarction is unclear. METHODS We conducted an international, double-blind, placebo-controlled trial involving patients with acute myocardial infarction, multivessel coronary artery disease, and additional cardiovascular risk factors. Patients were randomly assigned to receive either four weekly infusions of 6 g of CSL112 or matching placebo, with the first infusion administered within 5 days after the first medical contact for the acute myocardial infarction. The primary end point was a composite of myocardial infarction, stroke, or death from cardiovascular causes from randomization through 90 days of follow-up. RESULTS A total of 18,219 patients were included in the trial (9112 in the CSL112 group and 9107 in the placebo group). There was no significant difference between the groups in the risk of a primary end-point event at 90 days of follow-up (439 patients [4.8%] in the CSL112 group vs. 472 patients [5.2%] in the placebo group; hazard ratio, 0.93; 95% confidence interval [CI], 0.81 to 1.05; P = 0.24), at 180 days of follow-up (622 patients [6.9%] vs. 683 patients [7.6%]; hazard ratio, 0.91; 95% CI, 0.81 to 1.01), or at 365 days of follow-up (885 patients [9.8%] vs. 944 patients [10.5%]; hazard ratio, 0.93; 95% CI, 0.85 to 1.02). The percentage of patients with adverse events was similar in the two groups; a higher number of hypersensitivity events was reported in the CSL112 group. CONCLUSIONS Among patients with acute myocardial infarction, multivessel coronary artery disease, and additional cardiovascular risk factors, four weekly infusions of CSL112 did not result in a lower risk of myocardial infarction, stroke, or death from cardiovascular causes than placebo through 90 days. (Funded by CSL Behring; AEGIS-II ClinicalTrials.gov number, NCT03473223.).
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Affiliation(s)
- C Michael Gibson
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Danielle Duffy
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Serge Korjian
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - M Cecilia Bahit
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Gerald Chi
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - John H Alexander
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - A Michael Lincoff
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Mark Heise
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Pierluigi Tricoci
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Lawrence I Deckelbaum
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Sojaita Jenny Mears
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Jose C Nicolau
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Renato D Lopes
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Bela Merkely
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Basil S Lewis
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Jan H Cornel
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Jaroslaw Trebacz
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Alexander Parkhomenko
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Peter Libby
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Frank M Sacks
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Thomas J Povsic
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Marc Bonaca
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Shaun G Goodman
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Deepak L Bhatt
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Michal Tendera
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - P Gabriel Steg
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Paul M Ridker
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Philip Aylward
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - John J P Kastelein
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Christoph Bode
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Kenneth W Mahaffey
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Stephen J Nicholls
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Stuart J Pocock
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Roxana Mehran
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
| | - Robert A Harrington
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (C.M.G., S.K., G.C.), and the Department of Medicine, Cardiovascular Division (P.L.), and the Center for Cardiovascular Disease Prevention (P.M.R.), Brigham and Women's Hospital (F.M.S.), Harvard Medical School, and the Harvard T.H. Chan School of Public Health (F.M.S.) - all in Boston; CSL Behring, King of Prussia, PA (D.D., M.H., P.T., L.I.D., S.J.M.); INECO Neurociencias, Rosario, Argentina (M.C.B.); Duke Clinical Research Institute, Duke Health, Durham, NC (J.H.A., R.D.L., T.J.P.); the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (A.M.L.); Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (J.C.N.), and the Brazilian Clinical Research Institute (R.D.L.) - both in Sao Paulo; the Heart and Vascular Center of Semmelweis University, Budapest, Hungary (B.M.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar (J.H.C.), and the University of Amsterdam Academic Medical Center, Amsterdam (J.J.P.K.) - both in the Netherlands; Krakowski Szpital Specjalistyczny im. Jana Pawła II, Krakow (J.T.), and the Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice (M.T.) - both in Poland; the National Scientific Center, Kyiv, Ukraine (A.P.); the University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (M.B.); the Canadian VIGOUR Centre, University of Alberta, Edmonton, and St. Michael's Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto - all in Canada (S.G.G.); Mount Sinai Fuster Heart Hospital (D.L.B.) and Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, and Weill Cornell Medicine (R.A.H.) - both in New York; Université Paris-Cité, INSERM Unité 1148, FACT and Assistance Publique-Hopitaux de Paris, Hôpital Bichat, Paris (P.G.S.); South Australian Health and Medical Research Institute/SAHMRI, Adelaide, SA (P.A.), and Victorian Heart Institute, Monash University, Melbourne, VIC (S.J.N.) - both in Australia; the Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany (C.B.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and London School of Hygiene and Tropical Medicine, London (S.J.P.)
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6
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Abrahams T, Nicholls SJ, Nelson AJ. Optimal Medical Therapy for Stable Ischemic Heart Disease in 2024: Focus on Blood Pressure and Lipids. Med Clin North Am 2024; 108:441-453. [PMID: 38548456 DOI: 10.1016/j.mcna.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Hypertension and dyslipidemia are 2 highly prevalent and modifiable risk factors in patients with stable ischemic heart disease. Multiple lines of evidence demonstrate that lowering blood pressure and low-density lipoprotein cholesterol improves clinical outcomes in patients with ischemic heart disease. Accordingly, clinical guidelines recommend intensive treatment targets for these high-risk patients. This article summarizes the pathophysiology, supporting evidence, and treatment recommendations for management of hypertension and dyslipidemia among patients with manifest ischemic heart disease and points to future research and unmet clinical needs.
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Affiliation(s)
- Timothy Abrahams
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Adam J Nelson
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia.
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7
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Araki M, Park SJ, Dauerman HL, Uemura S, Kim JS, Di Mario C, Johnson TW, Guagliumi G, Kastrati A, Joner M, Holm NR, Alfonso F, Wijns W, Adriaenssens T, Nef H, Rioufol G, Amabile N, Souteyrand G, Meneveau N, Gerbaud E, Opolski MP, Gonzalo N, Tearney GJ, Bouma B, Aguirre AD, Mintz GS, Stone GW, Bourantas CV, Räber L, Gili S, Mizuno K, Kimura S, Shinke T, Hong MK, Jang Y, Cho JM, Yan BP, Porto I, Niccoli G, Montone RA, Thondapu V, Papafaklis MI, Michalis LK, Reynolds H, Saw J, Libby P, Weisz G, Iannaccone M, Gori T, Toutouzas K, Yonetsu T, Minami Y, Takano M, Raffel OC, Kurihara O, Soeda T, Sugiyama T, Kim HO, Lee T, Higuma T, Nakajima A, Yamamoto E, Bryniarski KL, Di Vito L, Vergallo R, Fracassi F, Russo M, Seegers LM, McNulty I, Park S, Feldman M, Escaned J, Prati F, Arbustini E, Pinto FJ, Waksman R, Garcia-Garcia HM, Maehara A, Ali Z, Finn AV, Virmani R, Kini AS, Daemen J, Kume T, Hibi K, Tanaka A, Akasaka T, Kubo T, Yasuda S, Croce K, Granada JF, Lerman A, Prasad A, Regar E, Saito Y, Sankardas MA, Subban V, Weissman NJ, Chen Y, Yu B, Nicholls SJ, Barlis P, West NEJ, Arbab-Zadeh A, Ye JC, Dijkstra J, Lee H, Narula J, Crea F, Nakamura S, Kakuta T, Fujimoto J, Fuster V, Jang IK. Author Correction: Optical coherence tomography in coronary atherosclerosis assessment and intervention. Nat Rev Cardiol 2024; 21:348. [PMID: 38110566 DOI: 10.1038/s41569-023-00982-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Affiliation(s)
| | | | | | | | - Jung-Sun Kim
- Yonsei University College of Medicine, Seoul, South Korea
| | | | - Thomas W Johnson
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Adnan Kastrati
- Technische Universität München and Munich Heart Alliance, Munich, Germany
| | | | | | | | - William Wijns
- National University of Ireland Galway and Saolta University Healthcare Group, Galway, Ireland
| | | | | | - Gilles Rioufol
- Hospices Civils de Lyon and Claude Bernard University, Lyon, France
| | | | | | | | | | | | - Nieves Gonzalo
- Hospital Clinico San Carlos, IdISSC, Universidad Complutense, Madrid, Spain
| | | | - Brett Bouma
- Massachusetts General Hospital, Boston, MA, USA
| | | | - Gary S Mintz
- Cardiovascular Research Foundation, New York, NY, USA
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christos V Bourantas
- Barts Health NHS Trust, University College London and Queen Mary University London, London, UK
| | - Lorenz Räber
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | | | | | - Myeong-Ki Hong
- Yonsei University College of Medicine, Seoul, South Korea
| | - Yangsoo Jang
- Yonsei University College of Medicine, Seoul, South Korea
| | | | - Bryan P Yan
- Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Italo Porto
- University of Genoa, Genoa, Italy, San Martino Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | | | - Rocco A Montone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | | | - Harmony Reynolds
- New York University Grossman School of Medicine, New York, NY, USA
| | - Jacqueline Saw
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Libby
- Brigham and Women's Hospital, Boston, MA, USA
| | - Giora Weisz
- New York Presbyterian Hospital, Columbia University Medical Center and Cardiovascular Research Foundation, New York, NY, USA
| | | | - Tommaso Gori
- Universitäts medizin Mainz and DZHK Rhein-Main, Mainz, Germany
| | | | | | | | | | | | - Osamu Kurihara
- Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | | | | | | | - Tetsumin Lee
- Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Takumi Higuma
- Kawasaki Municipal Tama Hospital, St. Marianna University School of Medicine, Kanagawa, Japan
| | | | - Erika Yamamoto
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Krzysztof L Bryniarski
- Jagiellonian University Medical College, Institute of Cardiology, Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | | | | | | | - Michele Russo
- Catholic University of the Sacred Heart, Rome, Italy
| | | | | | - Sangjoon Park
- Korea Advanced Institute of Science and Technology, Daejeon, South Korea
| | - Marc Feldman
- University of Texas Health, San Antonio, TX, USA
| | | | - Francesco Prati
- UniCamillus - Saint Camillus International University of Health Sciences, Rome, Italy
| | - Eloisa Arbustini
- IRCCS Foundation University Hospital Policlinico San Matteo, Pavia, Italy
| | - Fausto J Pinto
- Santa Maria University Hospital, CHULN Center of Cardiology of the University of Lisbon, Lisbon School of Medicine, Lisbon Academic Medical Center, Lisbon, Portugal
| | - Ron Waksman
- MedStar Washington Hospital Center, Washington, DC, USA
| | | | - Akiko Maehara
- Cardiovascular Research Foundation, New York, NY, USA
| | - Ziad Ali
- Cardiovascular Research Foundation, New York, NY, USA
| | | | | | | | - Joost Daemen
- Erasmus University Medical Centre, Rotterdam, Netherlands
| | | | - Kiyoshi Hibi
- Yokohama City University Medical Center, Kanagawa, Japan
| | | | | | | | - Satoshi Yasuda
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kevin Croce
- Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | | | | | | | | | | - Yundai Chen
- Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Bo Yu
- The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | | | - Peter Barlis
- University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Jong Chul Ye
- Korea Advanced Institute of Science and Technology, Daejeon, South Korea
| | | | - Hang Lee
- Massachusetts General Hospital, Boston, MA, USA
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Filippo Crea
- Catholic University of the Sacred Heart, Rome, Italy
| | | | | | - James Fujimoto
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Ik-Kyung Jang
- Massachusetts General Hospital, Boston, MA, USA.
- Kyung Hee University, Seoul, South Korea.
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8
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Chen RT, Nelson AJ, Tan S, Clark RA, Zoungas S, Nicholls SJ. The effectiveness of visualising plaque on cardiac computed tomography in modifying risk factors for cardiovascular disease: A systematic review. J Cardiovasc Comput Tomogr 2024; 18:223-232. [PMID: 38467535 DOI: 10.1016/j.jcct.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/30/2024] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of disease burden worldwide, with a significant proportion of cases and deaths attributable to modifiable risk factors. Recent interest has emerged in using cardiac computed tomography (CT) imaging as a tool to enhance motivation and drive positive behavioural changes. However, the impact of providing visual feedback of plaque from CT on risk factor control and individual health behaviours remains understudied. This study aimed to assess the effects of visual feedback from cardiac CT imaging on health-related behaviours and risk factor control. A systematic search of electronic databases was conducted, yielding nine studies (five randomised controlled trials and four observational studies) for analysis. The results varied, but based on the limited low-quality data, CT imaging appears to have short-term favourable effects on cholesterol levels and systolic blood pressure reductions, and positive dietary behavioural changes. Further research is warranted to better understand the long-term impact of cardiac CT imaging on health behaviours and risk factor modification.
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Affiliation(s)
- Ruofei Trophy Chen
- Monash Victorian Heart Institute, Monash University, 631 Blackburn Road, Clayton VIC 3168, Australia.
| | - Adam J Nelson
- Monash Victorian Heart Institute, Monash University, 631 Blackburn Road, Clayton VIC 3168, Australia.
| | - Sean Tan
- Monash Victorian Heart Institute, Monash University, 631 Blackburn Road, Clayton VIC 3168, Australia.
| | - Robyn A Clark
- College of Nursing and Health Sciences, Flinders University, Level 1, Room N103, Sturt North Sturt Rd, Bedford Park SA 5042, Australia.
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne VIC 3004, Australia.
| | - Stephen J Nicholls
- Monash Victorian Heart Institute, Monash University, 631 Blackburn Road, Clayton VIC 3168, Australia.
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9
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Nissen SE, Linnebjerg H, Nicholls SJ. Lepodisiran for Elevated Lipoprotein(a)-Reply. JAMA 2024; 331:1417-1418. [PMID: 38536166 DOI: 10.1001/jama.2024.0848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/24/2024]
Affiliation(s)
- Steven E Nissen
- Cleveland Clinic Center for Clinical Research, Cleveland, Ohio
| | | | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Clayton, Victoria, Australia
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Gaudet D, Pall D, Watts GF, Nicholls SJ, Rosenson RS, Modesto K, San Martin J, Hellawell J, Ballantyne CM. Plozasiran (ARO-APOC3) for Severe Hypertriglyceridemia: The SHASTA-2 Randomized Clinical Trial. JAMA Cardiol 2024:2817469. [PMID: 38583092 PMCID: PMC11000138 DOI: 10.1001/jamacardio.2024.0959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 03/22/2024] [Indexed: 04/08/2024]
Abstract
Importance Severe hypertriglyceridemia (sHTG) confers increased risk of atherosclerotic cardiovascular disease (ASCVD), nonalcoholic steatohepatitis, and acute pancreatitis. Despite available treatments, persistent ASCVD and acute pancreatitis-associated morbidity from sHTG remains. Objective To determine the tolerability, efficacy, and dose of plozasiran, an APOC3-targeted small interfering-RNA (siRNA) drug, for lowering triglyceride and apolipoprotein C3 (APOC3, regulator of triglyceride metabolism) levels and evaluate its effects on other lipid parameters in patients with sHTG. Design, Setting, and Participants The Study to Evaluate ARO-APOC3 in Adults With Severe Hypertriglyceridemia (SHASTA-2) was a placebo-controlled, double-blind, dose-ranging, phase 2b randomized clinical trial enrolling adults with sHTG at 74 centers across the US, Europe, New Zealand, Australia, and Canada from May 31, 2021, to August 31, 2023. Eligible patients had fasting triglyceride levels in the range of 500 to 4000 mg/dL (to convert to millimoles per liter, multiply by 0.0113) while receiving stable lipid-lowering treatment. Interventions Participants received 2 subcutaneous doses of plozasiran (10, 25, or 50 mg) or matched placebo on day 1 and at week 12 and were followed up through week 48. Main Outcomes and Measures The primary end point evaluated the placebo-subtracted difference in means of percentage triglyceride change at week 24. Mixed-model repeated measures were used for statistical modeling. Results Of 229 patients, 226 (mean [SD] age, 55 [11] years; 176 male [78%]) were included in the primary analysis. Baseline mean (SD) triglyceride level was 897 (625) mg/dL and plasma APOC3 level was 32 (16) mg/dL. Plozasiran induced significant dose-dependent placebo-adjusted least squares (LS)-mean reductions in triglyceride levels (primary end point) of -57% (95% CI, -71.9% to -42.1%; P < .001), driven by placebo-adjusted reductions in APOC3 of -77% (95% CI, -89.1% to -65.8%; P < .001) at week 24 with the highest dose. Among plozasiran-treated patients, 144 of 159 (90.6%) achieved a triglyceride level of less than 500 mg/dL. Plozasiran was associated with dose-dependent increases in low-density lipoprotein cholesterol (LDL-C) level, which was significant in patients receiving the highest dose (placebo-adjusted LS-mean increase 60% (95% CI, 31%-89%; P < .001). However, apolipoprotein B (ApoB) levels did not increase, and non-high-density lipoprotein cholesterol (HDL-C) levels decreased significantly at all doses, with a placebo-adjusted change of -20% at the highest dose. There were also significant durable reductions in remnant cholesterol and ApoB48 as well as increases in HDL-C level through week 48. Adverse event rates were similar in plozasiran-treated patients vs placebo. Serious adverse events were mild to moderate, not considered treatment related, and none led to discontinuation or death. Conclusions and Relevance In this randomized clinical trial of patients with sHTG, plozasiran decreased triglyceride levels, which fell below the 500 mg/dL threshold of acute pancreatitis risk in most participants. Other triglyceride-related lipoprotein parameters improved. An increase in LDL-C level was observed but with no change in ApoB level and a decrease in non-HDL-C level. The safety profile was generally favorable at all doses. Additional studies will be required to determine whether plozasiran favorably modulates the risk of sHTG-associated complications. Trial Registration ClinicalTrials.gov Identifier: NCT04720534.
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Affiliation(s)
- Daniel Gaudet
- ECOGENE-21 QC, Department of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Denes Pall
- Department of Medical Clinical Pharmacology, University of Debrecen, Debrecen, Hungary
| | - Gerald F. Watts
- Department of Cardiology, Royal Perth Hospital, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Stephen J. Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
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11
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Cho L, Plutzky J, Brennan D, Louie MJ, Lei L, Robinson P, Powell HA, Nicholls SJ, Lincoff AM, Nissen SE. Impact of Bempedoic Acid on Cardiovascular Outcomes by Sex. Circulation 2024. [PMID: 38581406 DOI: 10.1161/circulationaha.123.067691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/12/2024] [Indexed: 04/08/2024]
Affiliation(s)
| | | | | | | | - Lei Lei
- Esperion Therapeutics, Inc., Ann Arbor, MI
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12
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Povsic TJ, Korjian S, Bahit MC, Chi G, Duffy D, Alexander JH, Vinereanu D, Tricoci P, Mears SJ, Deckelbaum LI, Bonaca M, Ridker PM, Goodman SG, Cornel JH, Lewis BS, Parkhomenko A, Lopes RD, Aylward P, Lincoff AM, Heise M, Sacks F, Nicolau JC, Merkely B, Trebacz J, Libby P, Nicholls SJ, Pocock S, Bhatt DL, Kastelein J, Bode C, Mahaffey KW, Steg PG, Tendera M, Bainey KR, Harrington RA, Mehran R, Duerschmied D, Kingwell BA, Gibson CM. Effect of Reconstituted Human Apolipoprotein A-I on Recurrent Ischemic Events in Survivors of Acute MI. J Am Coll Cardiol 2024:S0735-1097(24)06702-0. [PMID: 38588930 DOI: 10.1016/j.jacc.2024.03.396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The AEGIS-II trial hypothesized that CSL112, an intravenous formulation of human apoA-I, would lower the risk of plaque disruption, decreasing the risk of recurrent events such as myocardial infarction (MI) among high-risk patients with MI. OBJECTIVES This exploratory analysis evaluates the effect of CSL112 therapy on the incidence of cardiovascular (CV) death and recurrent MI. METHODS The AEGIS-II trial was an international, multicenter, randomized, double-blind, placebo-controlled trial that randomized 18,219 high-risk acute MI patients to 4 weekly infusions of apoA-I (6 g CSL112) or placebo. RESULTS The incidence of the composite of CV death and type 1 MI was 11% to 16% lower in the CSL112 group over the study period (HR: 0.84; 95% CI: 0.7-1.0; P = 0.056 at day 90; HR: 0.86; 95% CI: 0.74-0.99; P = 0.048 at day 180; and HR: 0.89; 95% CI: 0.79-1.01; P = 0.07 at day 365). Similarly, the incidence of CV death or any MI was numerically lower in CSL112-treated patients throughout the follow-up period (HR: 0.92; 95% CI: 0.80-1.05 at day 90, HR: 0.89; 95% CI: 0.79-0.996 at day 180, HR: 0.91; 95% CI: 0.83-1.01 at day 365). The effect of CSL112 treatment on MI was predominantly observed for type 1 MI and type 4b (MI due to stent thrombosis). CONCLUSIONS Although CSL112 did not significantly reduce the occurrence of the primary study endpoints, patients treated with CSL112 infusions had numerically lower rates of CV death and MI, type-1 MI, and stent thrombosis-related MI compared with placebo. These findings could suggest a role of apoA-I in reducing subsequent plaque disruption events via enhanced cholesterol efflux. Further prospective data would be needed to confirm these observations.
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Affiliation(s)
- Thomas J Povsic
- Duke Clinical Research Institute/Duke University Medical Center, Durham, North Carolina, USA
| | - Serge Korjian
- PERFUSE Study Group, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Gerald Chi
- PERFUSE Study Group, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - John H Alexander
- Duke Clinical Research Institute/Duke University Medical Center, Durham, North Carolina, USA
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania
| | | | | | | | - Marc Bonaca
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Paul M Ridker
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Jan H Cornel
- Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Technion-Israel Institute of Technology, Aurora, Colorado, USA
| | | | - Renato D Lopes
- Duke Clinical Research Institute/Duke University Medical Center, Durham, North Carolina, USA
| | - Philip Aylward
- South Australian Health and Medical Research Institute/SAHMRI, Adelaide, South Australia, Australia
| | - A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio, USA
| | - Mark Heise
- CSL Behring, King of Prussia, Pennsylvania, USA
| | - Frank Sacks
- Department of Nutrition, Harvard School of Public Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Bela Merkely
- Heart and Vascular Center of Semmelweis University, Budapest, Hungary
| | - Jaroslaw Trebacz
- Krakowski Szpital Specjalistyczny im. Jana Pawła II, Kraków, Poland
| | - Peter Libby
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen J Nicholls
- Victorian Heart Hospital, Monash Heart and Intensive Care, Clayton, Victoria, Australia
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Kastelein
- Academic Medical Centre/University of Amsterdam, Amsterdam, the Netherlands
| | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, California, USA
| | - P Gabriel Steg
- Universite Paris-Cité, INSERM 1148, FACT, and AP-HP, Hôpital Bichat, Paris, France
| | - Michal Tendera
- Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Kevin R Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Daniel Duerschmied
- Cardiology, Angiology, Haemostaseology, and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | | | - C Michael Gibson
- PERFUSE Study Group, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Nelson AJ, Azzopardi R, Lam CS, Nicholls SJ. Reply: Low Asian Enrollment in Cardiometabolic Studies and the Importance of Trial Context. JACC Asia 2024; 4:343. [PMID: 38660104 PMCID: PMC11035946 DOI: 10.1016/j.jacasi.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
- Adam J. Nelson
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Robert Azzopardi
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Carolyn S.P. Lam
- National Heart Centre and SingHealth Duke-NUS Cardiovascular Sciences, Singapore
| | - Stephen J. Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
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Imazio M, Klein AL, Brucato A, Abbate A, Arad M, Cremer PC, Insalaco A, LeWinter MM, Lewis BS, Lin D, Luis SA, Nicholls SJ, Sutej P, Wasserstrum Y, Clair J, Agarwal I, Wang S, Paolini JF. Sustained Pericarditis Recurrence Risk Reduction With Long-Term Rilonacept. J Am Heart Assoc 2024; 13:e032516. [PMID: 38471825 PMCID: PMC11010039 DOI: 10.1161/jaha.123.032516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Rilonacept, a once-weekly interleukin-1 alpha and beta cytokine trap, reduced pericarditis recurrence in the phase 3 study, RHAPSODY (Rilonacept Inhibition of Interleukin-1 Alpha and Beta for Recurrent Pericarditis: A Pivotal Symptomatology and Outcomes Study). The RHAPSODY long-term extension further explored recurrent pericarditis natural history and treatment duration decision-making during 24 additional months of open-label rilonacept treatment. METHODS AND RESULTS Seventy-four patients commenced the long-term extension, with a median (maximum) total rilonacept duration of 22 (35) months. Individually, 18 months after the most proximal pericarditis recurrence, investigators decided to continue rilonacept on study, suspend rilonacept for off-treatment observation (rescue allowed), or discontinue the study. The annualized incidence of pericarditis recurrence on rilonacept up to the 18-month decision milestone was 0.04 events/patient-year versus 4.4 events/patient-year prestudy while on oral therapies. At the 18-month decision milestone, 64% (33/52) continued rilonacept, 15% (8/52) suspended rilonacept for observation, and 21% (11/52) discontinued the study. Among the 33 patients (1/33; 3.0%) continuing rilonacept (median time to recurrence could not be estimated due to too few events), a single recurrence occurred 4 weeks after a treatment interruption. Among patients suspending rilonacept, 75% (6/8) experienced recurrence (median time to recurrence, 11.8 weeks [95% CI, 3.7 weeks to not estimable]). There was a 98% reduction in risk of pericarditis recurrence among patients continuing rilonacept treatment after the 18-month decision milestone versus those suspending treatment for observation (hazard ratio, 0.02; P<0.0001). CONCLUSIONS In the RHAPSODY long-term extension, continued rilonacept treatment resulted in continued response; treatment suspension at the 18-month decision milestone was associated with pericarditis recurrence. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03737110.
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Affiliation(s)
- Massimo Imazio
- Department of Medicine (DMED), University of Udine and Cardiothoracic DepartmentUniversity Hospital Santa Maria della Misericordia, ASUFCUdineItaly
| | | | | | - Antonio Abbate
- Berne Cardiovascular Research Center, School of MedicineUniversity of VirginiaCharlottesvilleVAUSA
| | - Michael Arad
- Leviev Heart Center, Ramat GanTel Aviv University School of MedicineRamat GanIsrael
| | | | - Antonella Insalaco
- Division of Rheumatology, Ospedale Pediatrico Bambino GesùIRCCS [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center]RomeItaly
| | | | - Basil S. Lewis
- Lady Davis Carmel Medical Center and Technion‐Israel Institute of TechnologyHaifaIsrael
| | - David Lin
- Abbott Northwestern HospitalMinneapolisMNUSA
| | | | | | | | - Yishay Wasserstrum
- Leviev Heart Center, Ramat GanTel Aviv University School of MedicineRamat GanIsrael
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Wong NKP, Solly EL, Le R, Nankivell VA, Mulangala J, Psaltis PJ, Nicholls SJ, Ng MKC, Bursill CA, Tan JTM. TRIM2 Selectively Regulates Inflammation-Driven Pathological Angiogenesis without Affecting Physiological Hypoxia-Mediated Angiogenesis. Int J Mol Sci 2024; 25:3343. [PMID: 38542330 PMCID: PMC10970352 DOI: 10.3390/ijms25063343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/05/2024] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
Angiogenesis is a critical physiological response to ischemia but becomes pathological when dysregulated and driven excessively by inflammation. We recently identified a novel angiogenic role for tripartite-motif-containing protein 2 (TRIM2) whereby lentiviral shRNA-mediated TRIM2 knockdown impaired endothelial angiogenic functions in vitro. This study sought to determine whether these effects could be translated in vivo and to determine the molecular mechanisms involved. CRISPR/Cas9-generated Trim2-/- mice that underwent a periarterial collar model of inflammation-induced angiogenesis exhibited significantly less adventitial macrophage infiltration relative to wildtype (WT) littermates, concomitant with decreased mRNA expression of macrophage marker Cd68 and reduced adventitial proliferating neovessels. Mechanistically, TRIM2 knockdown in endothelial cells in vitro attenuated inflammation-driven induction of critical angiogenic mediators, including nuclear HIF-1α, and curbed the phosphorylation of downstream effector eNOS. Conversely, in a hindlimb ischemia model of hypoxia-mediated angiogenesis, there were no differences in blood flow reperfusion to the ischemic hindlimbs of Trim2-/- and WT mice despite a decrease in proliferating neovessels and arterioles. TRIM2 knockdown in vitro attenuated hypoxia-driven induction of nuclear HIF-1α but had no further downstream effects on other angiogenic proteins. Our study has implications for understanding the role of TRIM2 in the regulation of angiogenesis in both pathophysiological contexts.
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Affiliation(s)
- Nathan K. P. Wong
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.K.P.W.); (E.L.S.); (R.L.); (V.A.N.); (J.M.); (P.J.P.); (C.A.B.)
- Faculty of Medicine and Health, The University of Sydney School of Medicine, Camperdown, NSW 2050, Australia;
- Department of Cardiology, St. Vincent’s Hospital, Darlinghurst, NSW 2010, Australia
| | - Emma L. Solly
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.K.P.W.); (E.L.S.); (R.L.); (V.A.N.); (J.M.); (P.J.P.); (C.A.B.)
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia
| | - Richard Le
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.K.P.W.); (E.L.S.); (R.L.); (V.A.N.); (J.M.); (P.J.P.); (C.A.B.)
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5042, Australia
| | - Victoria A. Nankivell
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.K.P.W.); (E.L.S.); (R.L.); (V.A.N.); (J.M.); (P.J.P.); (C.A.B.)
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia
| | - Jocelyne Mulangala
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.K.P.W.); (E.L.S.); (R.L.); (V.A.N.); (J.M.); (P.J.P.); (C.A.B.)
- Heart Foundation, Brisbane, QLD 4000, Australia
| | - Peter J. Psaltis
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.K.P.W.); (E.L.S.); (R.L.); (V.A.N.); (J.M.); (P.J.P.); (C.A.B.)
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia
| | | | - Martin K. C. Ng
- Faculty of Medicine and Health, The University of Sydney School of Medicine, Camperdown, NSW 2050, Australia;
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Christina A. Bursill
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.K.P.W.); (E.L.S.); (R.L.); (V.A.N.); (J.M.); (P.J.P.); (C.A.B.)
- Faculty of Medicine and Health, The University of Sydney School of Medicine, Camperdown, NSW 2050, Australia;
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia
| | - Joanne T. M. Tan
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.K.P.W.); (E.L.S.); (R.L.); (V.A.N.); (J.M.); (P.J.P.); (C.A.B.)
- Faculty of Medicine and Health, The University of Sydney School of Medicine, Camperdown, NSW 2050, Australia;
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia
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16
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Monagle SR, Spear E, Abrahams T, Thakur U, Pol D, Tan S, Bellamy K, Hickman J, Jackson B, Chan J, Nicholls SJ, Nelson AJ. Cardiologists' knowledge and perceptions of the seasonal influenza immunisation. Int J Cardiol 2024; 399:131654. [PMID: 38104726 DOI: 10.1016/j.ijcard.2023.131654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/05/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Seasonal influenza immunisation reduces cardiovascular events in high-risk patients, but 50% do not receive routine immunisation. The perceptions and current role of cardiologists in recommending and prescribing influenza immunisation has not been well described. METHODS We used an exploratory sequential mixed methods design. Semi-structured interviews of 10 cardiologists were performed to identify themes for quantitative evaluation. 63 cardiologists undertook quantitative evaluation in an online survey. The interviews and surveys addressed (a) attitudes and behaviours regarding influenza immunisation and (b) preventative care in cardiology. RESULTS One quarter (25.4%, n = 16) of cardiologists recommended influenza immunisation to all patients. Less than half (49.2%, n = 31) recommended influenza immunisation to secondary prevention patients. Almost 1/3 of respondents (31.7%, n = 20) were uncertain or unaware of the guidelines regarding influenza immunisation and patients with cardiac disease. Most cardiologists believed that general practitioners were responsible for ensuring patients received influenza immunisation (76.2%, n = 48). CONCLUSIONS Despite reducing cardiovascular events in high-risk patients, influenza immunisation is not widely recommended by cardiologists. Further clinician education is needed to address the knowledge gaps which prevent recommendation and uptake of this guideline directed treatment.
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Affiliation(s)
- Sarah R Monagle
- Monash Heart, Monash Health, Victoria, Australia; Victorian Heart Institute, Monash University, Clayton, Australia
| | - Ella Spear
- Monash Heart, Monash Health, Victoria, Australia; Victorian Heart Institute, Monash University, Clayton, Australia
| | - Timothy Abrahams
- Monash Heart, Monash Health, Victoria, Australia; Victorian Heart Institute, Monash University, Clayton, Australia
| | - Udit Thakur
- Monash Heart, Monash Health, Victoria, Australia; Victorian Heart Institute, Monash University, Clayton, Australia
| | - Derk Pol
- Monash Heart, Monash Health, Victoria, Australia; Victorian Heart Institute, Monash University, Clayton, Australia
| | - Sean Tan
- Monash Heart, Monash Health, Victoria, Australia; Victorian Heart Institute, Monash University, Clayton, Australia
| | - Karen Bellamy
- Monash Health Infectious Diseases, Clayton, Australia
| | | | - Brendan Jackson
- Monash Heart, Monash Health, Victoria, Australia; Victorian Heart Institute, Monash University, Clayton, Australia
| | - Jasmine Chan
- Monash Heart, Monash Health, Victoria, Australia; Victorian Heart Institute, Monash University, Clayton, Australia
| | - Stephen J Nicholls
- Monash Heart, Monash Health, Victoria, Australia; Victorian Heart Institute, Monash University, Clayton, Australia
| | - Adam J Nelson
- Monash Heart, Monash Health, Victoria, Australia; Victorian Heart Institute, Monash University, Clayton, Australia.
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Nicholls SJ. Serial PET imaging to evaluate medical therapies: Is it ready for prime time? Atherosclerosis 2024:117517. [PMID: 38582638 DOI: 10.1016/j.atherosclerosis.2024.117517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 04/08/2024]
Affiliation(s)
- Stephen J Nicholls
- Victorian Heart Institute, Monash University, Melbourne, 631 Blackburn Road, Clayton, VIC, 3168, Australia.
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Tan S, Kader Z, Day D, Chen D, Nicholls SJ, Ramkumar S. Cardiotoxicity in Oncology Guidelines: Discrepancies Do Matter. Heart Lung Circ 2024:S1443-9506(24)00122-7. [PMID: 38453605 DOI: 10.1016/j.hlc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/29/2024] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Sean Tan
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia; Monash Heart, Victorian Heart Hospital, Melbourne, Vic, Australia.
| | - Zainel Kader
- Monash Heart, Victorian Heart Hospital, Melbourne, Vic, Australia
| | - Daphne Day
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Vic, Australia; Department of Oncology, Monash Health, Melbourne, Vic, Australia
| | - Daniel Chen
- Prince of Wales and St George Hospitals, South Eastern Sydney Local Health District, Sydney, NSW, Australia; Hatter Cardiovascular Institute, University College of London, London, UK
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia; Monash Heart, Victorian Heart Hospital, Melbourne, Vic, Australia
| | - Satish Ramkumar
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia; Monash Heart, Victorian Heart Hospital, Melbourne, Vic, Australia
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Beleigoli A, Foote J, Gebremichael LG, Bulamu NB, Astley C, Keech W, Tavella R, Gulyani A, Nesbitt K, Pinero de Plaza MA, Ramos JS, Ludlow M, Nicholls SJ, Chew DP, Beltrame J, Clark RA. Clinical Effectiveness and Utilisation of Cardiac Rehabilitation After Hospital Discharge: Data Linkage Analysis of 84,064 Eligible Discharged Patients (2016-2021). Heart Lung Circ 2024:S1443-9506(24)00048-9. [PMID: 38443278 DOI: 10.1016/j.hlc.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/12/2023] [Accepted: 01/11/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Despite the highest levels of evidence on cardiac rehabilitation (CR) effectiveness, its translation into practice is compromised by low participation. AIM This study aimed to investigate CR utilisation and effectiveness in South Australia. METHODS This retrospective cohort study used data linkage of clinical and administrative databases from 2016 to 2021 to assess the association between CR utilisation (no CR received, commenced without completing, or completed) and the composite primary outcome (mortality/cardiovascular re-admissions within 12 months after discharge). Cox survival models were adjusted for sociodemographic and clinical data and applied to a population balanced by inverse probability weighting. Associations with non-completion were assessed by logistic regression. RESULTS Among 84,064 eligible participants, 74,189 did not receive CR, with 26,833 of the 84,064 (31.9%) participants referred. Of these, 9,875 (36.8%) commenced CR, and 7,681 of the 9,875 (77.8%) completed CR. Median waiting time from discharge to commencement was 40 days (interquartile range, 23-79 days). Female sex (odds ratio [OR] 1.12; 95% CI 1.01-1.24; p=0.024), depression (OR 1.17; 95% CI 1.05-1.30; p=0.002), and waiting time >28 days (OR 1.15; 95% CI 1.05-1.26; p=0.005) were associated with higher odds of non-completion, whereas enrolment in a telehealth program (OR 0.35; 95% CI 0.31-0.40; p<0.001) was associated with lower odds of non-completion. Completing CR (hazard ratio [HR] 0.62; 95% CI 0.58-0.66; p<0.001) was associated with a lower risk of 12-month mortality/cardiovascular re-admissions. Commencing without completing was also associated with decreased risk (HR 0.81; 95% CI 0.73-0.90; p<0.001), but the effect was lower than for those completing CR (p<0.001). CONCLUSIONS Cardiac rehabilitation (CR) attendance is associated with lower all-cause mortality/cardiovascular re-admissions, with CR completion leading to additional benefits. Quality improvement initiatives should include promoting referral, women's participation, access to telehealth, and reduction of waiting times to increase completion.
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Affiliation(s)
- Alline Beleigoli
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.
| | - Jonathon Foote
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Lemlem G Gebremichael
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Norma B Bulamu
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Carolyn Astley
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Wendy Keech
- Health Translation SA, Adelaide, SA, Australia
| | - Rosanna Tavella
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Aarti Gulyani
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Katie Nesbitt
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | | | - Joyce S Ramos
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Marie Ludlow
- National Heart Foundation of Australia, Adelaide, SA, Australia
| | | | - Derek P Chew
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia; Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - John Beltrame
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Robyn A Clark
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia; Southern Adelaide Local Health Network, SA, Australia
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20
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Nicholls SJ, Nelson AJ, Lincoff AM, Brennan D, Ray KK, Cho L, Menon V, Li N, Bloedon L, Nissen SE. Impact of Bempedoic Acid on Total Cardiovascular Events: A Prespecified Analysis of the CLEAR Outcomes Randomized Clinical Trial. JAMA Cardiol 2024; 9:245-253. [PMID: 38231501 PMCID: PMC10794976 DOI: 10.1001/jamacardio.2023.5155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/11/2023] [Indexed: 01/18/2024]
Abstract
Importance The ATP citrate lyase (ACL) inhibitor, bempedoic acid, reduces low-density lipoprotein cholesterol (LDL-C) level and major adverse cardiovascular events (MACE) by 13% in patients at high cardiovascular risk with intolerance of statin and high-intensity statin medications. The effects of bempedoic acid on total cardiovascular events remain unknown. Objective To determine the impact of bempedoic acid on the total incidence of MACE. Design, Setting, and Participants Included in this prespecified analysis of the Cholesterol Lowering via Bempedoic Acid, an ACL-Inhibiting Regimen (CLEAR) Outcomes trial were patients with, or at high risk for, cardiovascular disease, with hypercholesterolemia and inability to take guideline-recommended statins. Study data were analyzed from December 2016 to November 2022. Interventions Patients were randomly assigned to treatment with bempedoic acid or placebo daily. Main Outcomes and Measures The primary end point was the time to first event for a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularization (MACE-4). The key secondary end point was time to first event for cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke (MACE-3). This prespecified analysis compared the total number of cardiovascular events in the treatment groups. Results A total of 13 970 patients (mean [SD] age, 65 [9] years; 7230 male [51.8%]) were included in the study. A total of 9764 participants (69.9%) had prior atherosclerotic cardiovascular disease and a baseline LDL-C level of 139 mg/dL; treatment with bempedoic acid resulted in a 21% reduction in LDL-C level and a 22% reduction in high-sensitivity C-reactive protein (hsCRP) level at 6 months. Median (IQR) follow-up was 3.4 (3.1-3.9) years. A total of 1746 positively adjudicated first MACE-4 events and 915 additional MACE events in 612 patients were recorded, with coronary revascularization representing 32.8% (573 of 1746) of first events and 69.4% (635 of 915) of additional events. For the total incidence of cardiovascular events, treatment with bempedoic acid was associated with a reduction in risk of MACE-4 (hazard ratio [HR], 0.80; 95% CI, 0.72-0.89; P <.001), MACE-3 (HR, 0.83; 95% CI, 0.73-0.93; P = .002), myocardial infarction (HR, 0.69; 95% CI, 0.58-0.83; P < .001), and coronary revascularization (HR, 0.78; 95% CI, 0.68-0.89; P <.001), although no statistically significant difference was observed for stroke (HR, 0.80; 95% CI, 0.63-1.03). A lower HR for protection with bempedoic acid was observed with increasing number of MACE events experienced by patients. Conclusion and Relevance Lowering LDL-C level with bempedoic acid reduced the total number of cardiovascular events in patients with high cardiovascular risk, statin therapy intolerance, and elevated LDL-C levels.
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Affiliation(s)
- Stephen J. Nicholls
- The Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Adam J. Nelson
- The Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - A. Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Danielle Brennan
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Kausik K. Ray
- School of Public Health, Imperial College London, London, United Kingdom
| | - Leslie Cho
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Venu Menon
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Na Li
- Esperion Therapeutics, Ann Arbor, Michigan
| | | | - Steven E. Nissen
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
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21
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Abrahams T, Nicholls SJ. Perspectives on the success of plasma lipidomics in cardiovascular drug discovery and future challenges. Expert Opin Drug Discov 2024; 19:281-290. [PMID: 38402906 DOI: 10.1080/17460441.2023.2292039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/04/2023] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Plasma lipidomics has emerged as a powerful tool in cardiovascular drug discovery by providing insights into disease mechanisms, identifying potential biomarkers for diagnosis and prognosis, and discovering novel targets for drug development. Widespread application of plasma lipidomics is hampered by technological limitations and standardization and requires a collaborative approach to maximize its use in cardiovascular drug discovery. AREAS COVERED This review provides an overview of the utility of plasma lipidomics in cardiovascular drug discovery and discusses the challenges and future perspectives of this rapidly evolving field. The authors discuss the role of lipidomics in understanding the molecular mechanisms of CVD, identifying novel biomarkers for diagnosis and prognosis, and discovering new therapeutic targets for drug development. Furthermore, they highlight the challenges faced in data analysis, standardization, and integration with other omics approaches and propose future directions for the field. EXPERT OPINION Plasma lipidomics holds great promise for improving the diagnosis, treatment, and prevention of CVD. While challenges remain in standardization and technology, ongoing research and collaboration among scientists and clinicians will undoubtedly help overcome these obstacles. As lipidomics evolves, its impact on cardiovascular drug discovery and clinical practice is expected to grow, ultimately benefiting patients and healthcare systems worldwide.
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Affiliation(s)
- Timothy Abrahams
- From the Victorian Heart Institute, Monash University, Melbourne, Australia
| | - Stephen J Nicholls
- From the Victorian Heart Institute, Monash University, Melbourne, Australia
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22
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Abrahams T, Nelson AJ, Nicholls SJ. How Will Our Practice Change After the CLEAR Outcomes Trial? Curr Atheroscler Rep 2024; 26:83-89. [PMID: 38294660 PMCID: PMC10881600 DOI: 10.1007/s11883-024-01188-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE OF REVIEW Bempedoic acid is a novel therapeutic agent that is designed to reduce levels of low-density lipoprotein cholesterol (LDL-C). The purpose of this review is to provide the background for development of bempedoic acid, findings from clinical trials and to discuss clinical implications. RECENT FINDINGS Bempedoic acid inhibits ATP citrate lyase within the liver and reduces cholesterol synthesis, with the potential to avoid muscle symptoms experienced by patients treated with statins. Early clinical studies demonstrated that administration of bempedoic acid resulted in lowering of LDL-C by 20-30% as monotherapy and by 40-50% when combined with ezetimibe, in addition to lowering of high sensitivity C-reactive protein by 20-30%. The CLEAR Outcomes trial of high cardiovascular risk patients, with elevated LDL-C levels and either unable or unwilling to take statins demonstrated that bempedoic acid reduced the rate of major adverse cardiovascular events. A greater incidence of elevation of hepatic transaminase and creatinine, gout, and cholelithiasis were consistently observed in bempedoic acid-treated patients. Bempedoic acid presents an additional therapeutic option to achieve more effective lowering of LDL-C levels and reduction in cardiovascular risk.
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Affiliation(s)
- Timothy Abrahams
- Victorian Heart Institute, MonashUniversity, 631 Blackburn Road, Clayton, VIC, 3168, Australia
| | - Adam J Nelson
- Victorian Heart Institute, MonashUniversity, 631 Blackburn Road, Clayton, VIC, 3168, Australia
| | - Stephen J Nicholls
- Victorian Heart Institute, MonashUniversity, 631 Blackburn Road, Clayton, VIC, 3168, Australia.
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23
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Muthalaly RG, Abrahams TB, Nerlekar N, Nelson AJ, Tan S, Chan J, Phan T, Ma H, Nicholls SJ. Asymptomatic coronary artery disease in ischaemic stroke survivors: A systematic review and meta-analysis. Eur Stroke J 2024:23969873241231702. [PMID: 38357886 DOI: 10.1177/23969873241231702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Ischaemic stroke and coronary artery disease share risk factors and stroke survivors experience a high rate of cardiac events. Recent work suggests a high burden of asymptomatic coronary artery disease (CAD) in ischaemic stroke survivors. Thus, we performed this systematic review and meta-analysis to A) estimate the prevalence of CAD in ischaemic stroke survivors without known CAD and B) evaluate the association between coronary atherosclerosis and future major adverse cardiovascular events (MACE) in stroke survivors. PATIENTS AND METHODS We conducted a systematic review and meta-analysis according to the PRISMA statement. We included studies investigating acute ischaemic stroke or transient ischaemic attack where participants underwent anatomical assessment of all coronary arteries. For objective B) we included studies that reported an association between coronary atherosclerosis and MACE. Two reviewers used the Newcastle-Ottawa Scale to assess risk of bias. We used random-effects modelling for our analyses. RESULTS We identified 2983 studies of which 17 were included. These studies had a total of 6862 participants between 2008 and 2022. The pooled prevalence of any coronary atherosclerosis was 66.8% (95% CI 57.2%-75.1%) with substantial heterogeneity (I2 = 95.2%). The pooled prevalence of obstructive (>50%) stenosis was 29.3% with substantial heterogeneity (I2 = 91%). High-risk coronary anatomy (triple vessel disease or left main stenosis) was found in 7.0% (95% CI 4%-12%) with high heterogeneity I2 = 72%. One study examined high-risk plaques and found a prevalence of 5.9%. Five studies reported the association of coronary atherosclerosis with future MACE. The presence of obstructive CAD confers a HR of 8.0 (95% CI 1.7-37.1, p = 0.007) for future MACE. DISCUSSION AND CONCLUSIONS Asymptomatic CAD is common in ischaemic stroke survivors. The presence and severity of asymptomatic CAD strongly associates with the risk of future MACE. Further evaluation of the benefits of routine coronary assessment in ischaemic stroke is warranted.
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Affiliation(s)
- Rahul G Muthalaly
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | | | - Nitesh Nerlekar
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | - Adam J Nelson
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | - Sean Tan
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | - Jasmine Chan
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | - Thanh Phan
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | - Henry Ma
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
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24
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Nicholls SJ, Tofé S, le Roux CW, D'Alessio DA, Wiese RJ, Pavo I, Brown K, Weerakkody GJ, Zeytinoglu M, Romera IC. Reduction of prevalence of patients meeting the criteria for metabolic syndrome with tirzepatide: a post hoc analysis from the SURPASS Clinical Trial Program. Cardiovasc Diabetol 2024; 23:63. [PMID: 38341541 PMCID: PMC10859014 DOI: 10.1186/s12933-024-02147-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Metabolic syndrome is characterized as the co-occurrence of interrelated cardiovascular risk factors, including insulin resistance, hyperinsulinemia, abdominal obesity, dyslipidemia and hypertension. Once weekly tirzepatide is approved in the US and EU for the treatment of type 2 diabetes (T2D) and obesity. In the SURPASS clinical trial program for T2D, tirzepatide demonstrated greater improvements in glycemic control, body weight reduction and other cardiometabolic risk factors versus placebo, subcutaneous semaglutide 1 mg, insulin degludec, and insulin glargine. This post hoc analysis assessed the effect of tirzepatide use on the prevalence of patients meeting the criteria for metabolic syndrome across SURPASS 1-5. METHODS Metabolic syndrome was defined as having ≥ 3 of 5 criteria according to the US National Cholesterol Education Program: Adult Treatment Panel III. Analyses were based on on-treatment data at the primary endpoint from patients adherent to treatment (taking ≥ 75% study drug). A logistic regression model with metabolic syndrome status as the response variable, metabolic syndrome status at the baseline visit as an adjustment, and randomized treatment as fixed explanatory effect was used. The effect of tirzepatide use on the prevalence of patients meeting the criteria for metabolic syndrome by categorical weight loss, background medication and gender were assessed. RESULTS In SURPASS, the prevalence of patients meeting the criteria for metabolic syndrome at baseline was 67-88% across treatment groups with reductions at the primary endpoint to 38-64% with tirzepatide versus 64-82% with comparators. Reductions in the prevalence of patients meeting the criteria for metabolic syndrome was significantly greater with all tirzepatide doses versus placebo, semaglutide 1 mg, insulin glargine, and insulin degludec (p < 0.001). Individual components of metabolic syndrome were also reduced to a greater extent with tirzepatide vs comparators. Greater reductions in body weight were associated with greater reductions in the prevalence of patients meeting the criteria for metabolic syndrome and its individual components. Background SGLT2i or sulfonylurea use or gender did not impact the change in prevalence of patients meeting the criteria for metabolic syndrome. CONCLUSIONS In this post hoc analysis, tirzepatide at all doses studied was associated with a greater reduction in the prevalence of patients meeting the criteria for metabolic syndrome compared to placebo, semaglutide 1 mg, insulin degludec, and insulin glargine. Although more evidence is needed, these data would support greater potential improvement in cardiovascular risk factor profile with tirzepatide treatment in people across the continuum of T2D.
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Affiliation(s)
| | - Santiago Tofé
- Department of Endocrinology and Nutrition, University Hospital Son Espases, Palma, Spain
| | - Carel W le Roux
- Diabetes Complications Research Centre, Conway Institute, School of Medicine, University College Dublin, Dublin, Ireland
- Diabetes Research Centre, Ulster University, Coleraine, UK
| | - David A D'Alessio
- Division of Endocrinology, Department of Medicine, Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | | | - Imre Pavo
- Eli Lilly Regional Operations GmbH, Vienna, Austria
| | | | | | | | - Irene C Romera
- Eli Lilly and Company, Avda. de La Industria 30, 28108, Alcobendas, Madrid, Spain.
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25
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Singleton AC, Redfern J, Diaz A, Koczwara B, Nicholls SJ, Negishi K, La Gerche A, Playford D, Conyers R, Cehic DA, Garvey G, Williams TD, Hunt L, Doyle K, Figtree GA, Ngo DTM, Sverdlov AL. Integrating CardioOncology Across the Research Pipeline, Policy, and Practice in Australia-An Australian Cardiovascular Alliance Perspective. Heart Lung Circ 2024:S1443-9506(24)00039-8. [PMID: 38336544 DOI: 10.1016/j.hlc.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/24/2023] [Accepted: 01/01/2024] [Indexed: 02/12/2024]
Abstract
Over 18 million people worldwide were diagnosed with cancer in 2020, including over 150,000 people in Australia. Although improved early detection and treatment have increased the survival rates, cardiotoxic treatment and inadequate management of cardiovascular risk factors have resulted in cardiovascular disease (CVD) being one of the leading causes of non-cancer-related death and disability among cancer survivors. International guidelines outline the standards of care for CVD risk surveillance and management. However, Australian cardio-oncology policies and clinical guidelines are limited. There is increasing growth of cardio-oncology research in Australia and support from leading Australian professional bodies and advocacy and research networks, including the Cardiac Society of Australia and New Zealand, the Clinical Oncology Society of Australia, the National Heart Foundation of Australia, and the Australian Cardiovascular Alliance (ACvA). Thus, opportunities to drive multidisciplinary cardio-oncology initiatives are growing, including grant funding, position statements, and novel research to inform new policies. The ACvA has a unique flagship structure that spans the translational research pipeline from drug discovery to implementation science. This article aims to highlight how multidisciplinary cardio-oncology innovations could intersect with the seven ACvA flagships, and to showcase Australian achievements in cardio-oncology thus far. We summarise eight key priority areas for future cardio-oncology research that emerged. These strategies will strengthen cardio-oncology research and care in Australia, and drive new guidelines, policies, and government initiatives to ensure equity in health outcomes for all cardio-oncology patients.
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Affiliation(s)
- Anna C Singleton
- Faculty of Medicine and Health, The University of Sydney School of Health Sciences, Sydney, NSW, Australia
| | - Julie Redfern
- Faculty of Medicine and Health, The University of Sydney School of Health Sciences, Sydney, NSW, Australia; George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Abbey Diaz
- First Nations Cancer and Wellbeing Research Program, School of Public Health, University of Queensland, Qld, Australia
| | - Bogda Koczwara
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia; Flinders Medical Centre, Adelaide, SA, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Monash Victorian Heart Institute, Monash University and MonashHeart, Monash Health, Clayton, Vic, Australia; Department of Medicine, Monash University, Clayton, Vic, Australia
| | - Kazuaki Negishi
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, Sydney, NSW, Australia
| | - Andre La Gerche
- St Vincent's Institute, Melbourne, Vic, Australia; The University of Melbourne, Melbourne, Vic, Australia
| | - David Playford
- The University of Notre Dame Australia, Fremantle, WA, Australia
| | - Rachel Conyers
- Heart Disease Team, Murdoch Children's Research Institute, Melbourne, Vic, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Vic, Australia; Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Vic, Australia
| | | | - Gail Garvey
- First Nations Cancer and Wellbeing Research Program, School of Public Health, University of Queensland, Qld, Australia
| | - Trent D Williams
- Newcastle Centre of Excellence in Cardio-Oncology, The University of Newcastle, Hunter Medical Research Institute, Calvary Mater Newcastle, Newcastle, NSW, Australia; College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, NSW, Australia; Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia
| | - Lee Hunt
- Cancer Voices NSW, Sydney, NSW, Australia
| | - Kerry Doyle
- Australian Cardiovascular Alliance, Chittaway Bay, NSW, Australia; University of Tasmania, Burnie, Tas, Australia; University of Wollongong, Wollongong, NSW, Australia
| | - Gemma A Figtree
- Faculty of Medicine and Health, The University of Sydney School of Health Sciences, Sydney, NSW, Australia; Australian Cardiovascular Alliance, Chittaway Bay, NSW, Australia
| | - Doan T M Ngo
- Newcastle Centre of Excellence in Cardio-Oncology, The University of Newcastle, Hunter Medical Research Institute, Calvary Mater Newcastle, Newcastle, NSW, Australia; College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, NSW, Australia.
| | - Aaron L Sverdlov
- Newcastle Centre of Excellence in Cardio-Oncology, The University of Newcastle, Hunter Medical Research Institute, Calvary Mater Newcastle, Newcastle, NSW, Australia; College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, NSW, Australia; Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia.
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26
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Desson Z, Sharman JE, Searles A, Schutte AE, Delles C, Olsen MH, Ordunez P, Hure A, Morton R, Figtree G, Webster J, Jennings G, Redfern J, Nicholls SJ, McNamara M, Deeming S, Doyle K, Ramanathan S. Improving the accuracy of blood pressure measuring devices in Australia: a modelled return on investment study. J Hum Hypertens 2024; 38:177-186. [PMID: 37938294 PMCID: PMC10844083 DOI: 10.1038/s41371-023-00866-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 04/20/2023] [Accepted: 07/10/2023] [Indexed: 11/09/2023]
Abstract
The VALID BP project was initiated to increase the availability of validated blood pressure measuring devices (BPMDs). The goal is to eliminate non validated BPMDs and minimise over- and underdiagnosis of hypertension caused by inaccurate readings. This study was undertaken to assess the potential return on investment in the VALID BP project. The Framework to Assess the Impact of Translational Health Research was applied to the VALID BP project. This paper focuses on the implementation of the cost benefit analysis aspect of this framework to monetise past research investment and model future research costs, implementation costs, and benefits. Analysis was based on reasoned assumptions about potential impacts from availability and use of validated BPMDs (assuming an end goal of 100% validated BPMDs available in Australia by 2028) and improved skills leading to more accurate BP measurement. After 5 years, with 20% attribution of benefits, there is a potential $1.14-$1.30 return for every dollar spent if the proportion of validated BPMDs and staff trained in proper BP measurement technique increased from 20% to 60%. After eight years (2020-2028) and assuming universal validation and training coverage, the returns would be between $2.70 and $3.20 per dollar spent (not including cost of side effects of unnecessary medication or downstream patient impacts from unmanaged hypertension). This modelled economic analysis indicates there will be positive downstream economic benefits if the availability of validated BPMDs is increased. The findings support ongoing efforts toward a universal regulatory framework for BPMDs and can be considered within more detailed future economic analyses.
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Affiliation(s)
- Zachary Desson
- Health Research Economics, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Andrew Searles
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Aletta E Schutte
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Pedro Ordunez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Alexis Hure
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Rachael Morton
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Gemma Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Australian Cardiovascular Alliance, Chittaway Bay, NSW, Australia
| | - Jacqui Webster
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Garry Jennings
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Australian Cardiovascular Alliance, Chittaway Bay, NSW, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Julie Redfern
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
| | | | | | - Simon Deeming
- Health Research Economics, Hunter Medical Research Institute, Newcastle, NSW, Australia
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Kerry Doyle
- Australian Cardiovascular Alliance, Chittaway Bay, NSW, Australia
| | - Shanthi Ramanathan
- Health Research Economics, Hunter Medical Research Institute, Newcastle, NSW, Australia.
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.
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Abstract
Hypercholesterolaemia is one of the most common conditions treated by clinicians in Australia. Low-density lipoprotein cholesterol (LDL-C) plays a causal role in the development and progression of atherosclerosis and cardiovascular disease. Every 1 mmol/L reduction in LDL-C concentration is associated with a 21 to 25% reduction in the relative risk of prospective atherosclerotic cardiovascular events, and emerging evidence suggests this benefit increases over time. Absolute cardiovascular risk assessment identifies patients likely to derive the most benefit from lowering LDL-C concentration, and helps determine the intensity of their treatment regimens and targets. Optimal management of LDL-C may require combination treatment with multiple classes of drugs.
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Affiliation(s)
- Adam J Nelson
- Royal Adelaide Hospital
- Victorian Heart Institute, Monash University, Melbourne
- Victorian Heart Hospital, MonashHeart and Intensive Care, Monash Health, Melbourne
| | - Stephen J Nicholls
- Royal Adelaide Hospital
- Victorian Heart Institute, Monash University, Melbourne
- Victorian Heart Hospital, MonashHeart and Intensive Care, Monash Health, Melbourne
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Ridker PM, Lei L, Louie MJ, Haddad T, Nicholls SJ, Lincoff AM, Libby P, Nissen SE. Inflammation and Cholesterol as Predictors of Cardiovascular Events Among 13 970 Contemporary High-Risk Patients With Statin Intolerance. Circulation 2024; 149:28-35. [PMID: 37929602 PMCID: PMC10752259 DOI: 10.1161/circulationaha.123.066213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Among patients treated with statin therapy to guideline-recommended cholesterol levels, residual inflammatory risk assessed by high-sensitivity C-reactive protein (hsCRP) is at least as strong a predictor of future cardiovascular events as is residual risk assessed by low-density lipoprotein cholesterol (LDLC). Whether these relationships are present among statin-intolerant patients with higher LDLC levels is uncertain but has implications for the choice of preventive therapies, including bempedoic acid, an agent that reduces both LDLC and hsCRP. METHODS The multinational CLEAR-Outcomes trial (Cholesterol Lowering via Bempedoic Acid, an ACL-Inhibiting Regimen Outcomes Trial) randomly allocated 13 970 statin-intolerant patients to 180 mg of oral bempedoic acid daily or matching placebo and followed them for a 4-component composite of incident myocardial infarction, stroke, coronary revascularization, or cardiovascular death, and for all-cause mortality. Quartiles of increasing baseline hsCRP and LDLC were assessed as predictors of future adverse events after adjustment for traditional risk factors and randomized treatment assignment. RESULTS Compared with placebo, bempedoic acid reduced median hsCRP by 21.6% and mean LDLC levels by 21.1% at 6 months. Baseline hsCRP was significantly associated with the primary composite end point of major cardiovascular events (highest versus lowest hsCRP quartile; hazard ratio [HR], 1.43 [95% CI, 1.24-1.65]), cardiovascular mortality (HR, 2.00 [95% CI, 1.53-2.61]), and all-cause mortality (HR, 2.21 [95% CI, 1.79-2.73]). By contrast, the relationship of baseline LDLC quartile (highest versus lowest) to future events was smaller in magnitude for the primary composite cardiovascular end point (HR, 1.19 [95% CI, 1.04-1.37]) and neutral for cardiovascular mortality (HR, 0.90 [95% CI, 0.70-1.17]) and all-cause mortality (HR, 0.95 [95% CI, 0.78-1.16]). Risks were high for those with elevated hsCRP irrespective of LDLC level. Bempedoic acid demonstrated similar efficacy in reducing cardiovascular events across all levels of hsCRP and LDLC. CONCLUSIONS Among contemporary statin-intolerant patients, inflammation assessed by hsCRP predicted risk for future cardiovascular events and death more strongly than hyperlipidemia assessed by LDLC. Compared with placebo, bempedoic acid had similar efficacy for reducing cardiovascular risk across hsCRP and LDLC strata. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02993406.
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Affiliation(s)
- Paul M Ridker
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine and the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.M.R., P.L.)
| | - Lei Lei
- Esperion Therapeutics, Ann Arbor, MI (L.L., M.J.L.)
| | | | - Tariq Haddad
- Inova Heart and Vascular Institute, Falls Church, VA (T.H.)
| | | | | | - Peter Libby
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine and the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.M.R., P.L.)
| | - Steven E. Nissen
- The Cleveland Clinic Heart and Vascular Institute, OH (A.M.L., S.E.N.)
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Bays HE, Bloedon LT, Lin G, Powell HA, Louie MJ, Nicholls SJ, Lincoff AM, Nissen SE. Safety of bempedoic acid in patients at high cardiovascular risk and with statin intolerance. J Clin Lipidol 2024; 18:e59-e69. [PMID: 37951797 DOI: 10.1016/j.jacl.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Bempedoic acid is an oral adenosine triphosphate citrate lyase (ACL) inhibitor that lowers low-density lipoprotein cholesterol (LDL-C) blood levels. The Cholesterol Lowering via Bempedoic acid, an ACL-Inhibiting Regimen (CLEAR) Outcomes study demonstrated that bempedoic acid reduced cardiovascular (CV) risk in patients at high risk for CV events who were unwilling or unable to take guideline-recommended doses of statins. OBJECTIVE To describe detailed safety information from CLEAR Outcomes, including events in the United States (US) prescribing information based on previous phase 3 hyperlipidemia studies. METHODS CLEAR Outcomes was a double-blind trial conducted in 13,970 patients randomized to oral bempedoic acid 180 mg daily or placebo and followed for a median of 3.4 years. RESULTS In patients who received at least one dose (7,001 bempedoic acid, 6,964 placebo), treatment emergent adverse events (AE) occurred in 86.3 % and 85 % of patients, respectively. COVID-19 was the most frequently reported AE in both groups. Changes in serum creatinine, blood urea nitrogen, hemoglobin, aminotransaminases, and uric acid were consistent with the known safety profile of bempedoic acid. Gout or gouty arthritis occurred in 3.2 % of bempedoic acid and 2.2 % of placebo patients. AE associated with tendinopathies, including tendon rupture, occurred in 2 % of patients in both treatment groups. Cholelithiasis occurred in 2.2 % of bempedoic acid and 1.2 % of placebo patients; AE related to gallbladder disease were similar between treatment groups. CONCLUSIONS Bempedoic acid was well-tolerated compared with placebo. Safety data from the long-term CLEAR Outcomes study reinforce the positive benefit-risk profile of bempedoic acid.
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Affiliation(s)
- Harold E Bays
- Louisville Metabolic and Atherosclerosis Research Center, 3288 Illinois Avenue, Louisville, KY 40213, USA (Dr Bays).
| | - LeAnne T Bloedon
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arobor, MI 48108, USA (Drs Bloedon, Lin, Powell and Louie)
| | - Grace Lin
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arobor, MI 48108, USA (Drs Bloedon, Lin, Powell and Louie)
| | - Heather A Powell
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arobor, MI 48108, USA (Drs Bloedon, Lin, Powell and Louie)
| | - Michael J Louie
- Esperion Therapeutics, Inc., 3891 Ranchero Drive, Suite 150, Ann Arobor, MI 48108, USA (Drs Bloedon, Lin, Powell and Louie)
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, 631 Blackburn Rd, Clayton VIC 3168, Australia (Dr Nicholls)
| | - A Michael Lincoff
- Cleveland Clinic, 9500 Euclid Avenue, Rm JB-820, Cleveland, OH 44195, USA (Drs Lincoff and Nissen)
| | - Steven E Nissen
- Cleveland Clinic, 9500 Euclid Avenue, Rm JB-820, Cleveland, OH 44195, USA (Drs Lincoff and Nissen)
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Nicholls SJ, Bhatt DL, Buse JB, Prato SD, Kahn SE, Lincoff AM, McGuire DK, Nauck MA, Nissen SE, Sattar N, Zinman B, Zoungas S, Basile J, Bartee A, Miller D, Nishiyama H, Pavo I, Weerakkody G, Wiese RJ, D'Alessio D. Comparison of tirzepatide and dulaglutide on major adverse cardiovascular events in participants with type 2 diabetes and atherosclerotic cardiovascular disease: SURPASS-CVOT design and baseline characteristics. Am Heart J 2024; 267:1-11. [PMID: 37758044 DOI: 10.1016/j.ahj.2023.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/11/2023] [Accepted: 09/16/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Tirzepatide, a once-weekly GIP/GLP-1 receptor agonist, reduces blood glucose and body weight in people with type 2 diabetes. The cardiovascular (CV) safety and efficacy of tirzepatide have not been definitively assessed in a cardiovascular outcomes trial. METHODS Tirzepatide is being studied in a randomized, double-blind, active-controlled CV outcomes trial. People with type 2 diabetes aged ≥40 years, with established atherosclerotic CV disease, HbA1c ≥7% to ≤10.5%, and body mass index ≥25 kg/m2 were randomized 1:1 to once weekly subcutaneous injection of either tirzepatide up to 15 mg or dulaglutide 1.5 mg. The primary outcome is time to first occurrence of any major adverse cardiovascular event (MACE), defined as CV death, myocardial infarction, or stroke. The trial is event-driven and planned to continue until ≥1,615 participants experience an adjudication-confirmed component of MACE. The primary analysis is noninferiority for time to first MACE of tirzepatide vs dulaglutide by demonstrating an upper confidence limit <1.05, which will also confirm superiority vs a putative placebo, and also to determine whether tirzepatide produces a greater CV benefit than dulaglutide (superiority analysis). RESULTS Over 2 years, 13,299 people at 640 sites in 30 countries across all world regions were randomized. The mean age of randomized participants at baseline was 64.1 years, diabetes duration 14.7 years, HbA1c 8.4%, and BMI 32.6 kg/m2. Overall, 65.0% had coronary disease, of whom 47.3% reported prior myocardial infarction and 57.4% had prior coronary revascularization. 19.1% of participants had a prior stroke and 25.3% had peripheral artery disease. The trial is fully recruited and ongoing. CONCLUSION SURPASS-CVOT will provide definitive evidence as to the CV safety and efficacy of tirzepatide as compared with dulaglutide, a GLP-1 receptor agonist with established CV benefit.
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Affiliation(s)
- Stephen J Nicholls
- Victorian Heart Institute, Monash University, VIC, Melbourne, Australia.
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY
| | - John B Buse
- University of North Carolina, Chapel Hill, NC
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and Diabetes, University of Pisa, Pisa, and Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Steven E Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle, WA
| | - A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research) and Department of Cardiovascular Medicine, Cleveland, OH
| | - Darren K McGuire
- University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - Michael A Nauck
- Diabetes, Endocrinology and Metabolism Section, Department of Medicine I, St. Josef-Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University of Bochum, Bochum, Germany
| | - Steven E Nissen
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research) and Department of Cardiovascular Medicine, Cleveland, OH
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom
| | - Bernard Zinman
- University of Toronto, Lunenfeld-Tanenbaum Research Institute and Mount Sinai Hospital, Toronto, ON, Canada
| | - Sophia Zoungas
- Victorian Heart Institute, Monash University, VIC, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia
| | - Jan Basile
- Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston, SC
| | | | | | | | - Imre Pavo
- Eli Lilly and Company, Indianapolis, IN
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Ray KK, Nicholls SJ, Li N, Louie MJ, Brennan D, Lincoff AM, Nissen SE. Efficacy and safety of bempedoic acid among patients with and without diabetes: prespecified analysis of the CLEAR Outcomes randomised trial. Lancet Diabetes Endocrinol 2024; 12:19-28. [PMID: 38061370 DOI: 10.1016/s2213-8587(23)00316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/06/2023] [Accepted: 10/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Statins reduce LDL cholesterol and cardiovascular events among those with or without diabetes but have been reported to increase new-onset diabetes. The CLEAR Outcomes trial demonstrated that bempedoic acid reduced the risk of major adverse cardiovascular events among statin-intolerant patients at high cardiovascular risk. In this prespecified analysis, our dual aims were to evaluate the cardiovascular benefits of bempedoic acid, an ATP-citrate lyase inhibitor, in individuals with diabetes, and to evaluate the risk of new-onset diabetes and HbA1c among those without diabetes in the CLEAR Outcomes trial. METHODS CLEAR Outcomes was a randomised, double-blind, placebo-controlled trial conducted across 1250 primary care and outpatient sites in 32 countries. Patients with or without cardiovascular disease who were unwilling or unable to take guideline-recommended doses of statins and an LDL cholesterol of 2·59 mmol/L or more were randomly assigned (1:1) in a double-blinded manner to either bempedoic acid 180 mg once per day or placebo. In this prespecified analysis, the efficacy endpoint was a time-to-event analysis of four-component major adverse cardiovascular event (MACE-4), which is the composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularisation, using the intention-to-treat population stratified by baseline glycaemia status. The prespecified analysis of risk of new-onset diabetes and HbA1c increase was evaluated in patients without diabetes at baseline. The CLEAR Outcomes trial was completed on Nov 7, 2022, and is registered with ClinicalTrials.gov (NCT02993406). FINDINGS Between Dec 22, 2016, and Nov 7, 2022, 13 970 patients were screened and randomly assigned; 6373 (45·6%) with diabetes, 5796 (41·5%) with prediabetes, and 1801 (12·9%) with normoglycaemia. Over a median of 3·4 years follow up, patients with diabetes had significant relative and absolute cardiovascular risk reductions in MACE-4 endpoints with bempedoic acid (HR 0·83; 95% CI 0·72-0·95; absolute risk reduction of 2·4%) compared to placebo, with no statistical evidence of effect modification across glycaemic strata (interaction p=0·42). The proportion of patients who developed new-onset diabetes were similar between the bempedoic acid and placebo groups, with 429 of 3848 (11·1%) with bempedoic acid versus 433 of 3749 (11·5%) with placebo (HR 0·95; 95% CI 0·83-1·09). HbA1c concentrations at month 12 and the end of the study were similar between randomised groups in patients who had prediabetes and normoglycaemia. Placebo-corrected LDL cholesterol concentrations and high-sensitivity C-reactive protein at 6 months were reduced in each glycaemic stratum (diabetes, prediabtes, and normoglycaemia) for patients randomly assigned to bempedoic acid (all p<0·001). INTERPRETATION Among patients with diabetes, bempedoic acid reduces LDL cholesterol and high-sensitivity C-reactive protein and risk of cardiovascular events. Patients without diabetes had no increase in new-onset diabetes or worsening HbA1c with bempedoic acid. The efficacy and cardiometabolic safety profile of bempedoic acid makes it a clinical option for those with and without diabetes. FUNDING Esperion Therapeutics.
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Affiliation(s)
- Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, Imperial College London, London, UK.
| | | | - Na Li
- Esperion Therapeutics, Ann Arbor, MI, USA
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Nissen SE, Linnebjerg H, Shen X, Wolski K, Ma X, Lim S, Michael LF, Ruotolo G, Gribble G, Navar AM, Nicholls SJ. Lepodisiran, an Extended-Duration Short Interfering RNA Targeting Lipoprotein(a): A Randomized Dose-Ascending Clinical Trial. JAMA 2023; 330:2075-2083. [PMID: 37952254 PMCID: PMC10641766 DOI: 10.1001/jama.2023.21835] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/04/2023] [Indexed: 11/14/2023]
Abstract
Importance Epidemiological and genetic data have implicated lipoprotein(a) as a potentially modifiable risk factor for atherosclerotic disease and aortic stenosis, but there are no approved pharmacological treatments. Objectives To assess the safety, tolerability, pharmacokinetics, and effects of lepodisiran on lipoprotein(a) concentrations after single doses of the drug; lepodisiran is a short interfering RNA directed at hepatic synthesis of apolipoprotein(a), an essential component necessary for assembly of lipoprotein(a) particles. Design, Setting, and Participants A single ascending-dose trial conducted at 5 clinical research sites in the US and Singapore that enrolled 48 adults without cardiovascular disease and with lipoprotein(a) serum concentrations of 75 nmol/L or greater (or ≥30 mg/dL) between November 18, 2020, and December 7, 2021; the last follow-up visit occurred on November 9, 2022. Interventions Participants were randomized to receive placebo or a single dose of lepodisiran (4 mg, 12 mg, 32 mg, 96 mg, 304 mg, or 608 mg) administered subcutaneously. Main Outcomes and Measures The primary outcome was the safety and tolerability of the single ascending doses of lepodisiran. The secondary outcomes included plasma levels of lepodisiran for 168 days after dose administration and changes in fasting lipoprotein(a) serum concentrations through a maximum follow-up of 336 days (48 weeks). Results Of the 48 participants enrolled (mean age, 46.8 [SD, 11.6] years; 35% were women), 1 serious adverse event occurred. The plasma concentrations of lepodisiran reached peak levels within 10.5 hours and were undetectable by 48 hours. The median baseline lipoprotein(a) concentration was 111 nmol/L (IQR, 78 to 134 nmol/L) in the placebo group, 78 nmol/L (IQR, 50 to 152 nmol/L) in the 4 mg of lepodisiran group, 97 nmol/L (IQR, 86 to 107 nmol/L) in the 12-mg dose group, 120 nmol/L (IQR, 110 to 188 nmol/L) in the 32-mg dose group, 167 nmol/L (IQR, 124 to 189 nmol/L) in the 96-mg dose group, 96 nmol/L (IQR, 72 to 132 nmol/L) in the 304-mg dose group, and 130 nmol/L (IQR, 87 to 151 nmol/L) in the 608-mg dose group. The maximal median change in lipoprotein(a) concentration was -5% (IQR, -16% to 11%) in the placebo group, -41% (IQR, -47% to -20%) in the 4 mg of lepodisiran group, -59% (IQR, -66% to -53%) in the 12-mg dose group, -76% (IQR, -76% to -75%) in the 32-mg dose group, -90% (IQR, -94% to -85%) in the 96-mg dose group, -96% (IQR, -98% to -95%) in the 304-mg dose group, and -97% (IQR, -98% to -96%) in the 608-mg dose group. At day 337, the median change in lipoprotein(a) concentration was -94% (IQR, -94% to -85%) in the 608 mg of lepodisiran group. Conclusions and Relevance In this phase 1 study of 48 participants with elevated lipoprotein(a) levels, lepodisiran was well tolerated and produced dose-dependent, long-duration reductions in serum lipoprotein(a) concentrations. The findings support further study of lepodisiran. Trial Registration ClinicalTrials.gov Identifier: NCT04914546.
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Affiliation(s)
| | | | - Xi Shen
- Eli Lilly and Company, Indianapolis, Indiana
| | - Kathy Wolski
- Cleveland Clinic Center for Clinical Research, Cleveland, Ohio
| | - Xiaosu Ma
- Eli Lilly and Company, Indianapolis, Indiana
| | - Shufen Lim
- Eli Lilly and Company, Indianapolis, Indiana
| | | | | | - Grace Gribble
- Cleveland Clinic Center for Clinical Research, Cleveland, Ohio
| | - Ann Marie Navar
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
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Al-Mukhtar O, Stub D, Reid CM, Lo S, Lefkovits J, Walton A, Chew DP, Yong A, Nicholls SJ, Cox N, Peter K, Chan W. Variability in Contemporary Heparin Prescription and Activated Clotting Time Monitoring During Percutaneous Coronary Intervention: Call for Up-To-Date Evidence-Based Guidelines. Heart Lung Circ 2023; 32:1475-1481. [PMID: 37993342 DOI: 10.1016/j.hlc.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/17/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Unfractionated heparin (UFH) is the preferred anticoagulant agent in percutaneous coronary intervention (PCI) procedures for minimising the risk of thrombotic complications. Because of the narrow therapeutic range of UFH, some society guidelines have advocated the use of the activated clotting time (ACT) test to monitor anticoagulation intensity during PCI to reduce thrombotic and bleeding complications. We aimed to assess the current practice of UFH prescription and its monitoring in Australia and New Zealand (ANZ). METHOD We conducted an anonymous voluntary cross-sectional survey of interventional cardiologists (ICs) who were members of the Cardiac Society of Australia and New Zealand in 2022. The survey included 10 questions pertaining to the current practice of anticoagulation during PCI. RESULTS Of 430 ICs surveyed, 148 responded (response rate, 34.4%). Most ICs (84.4%) prescribed 70-100 IU/kg of UFH for PCI. Over half of ICs (58.7%) routinely measured ACT during PCI, whereas only 22.2% routinely measured ACT after PCI to guide additional UFH prescription. Among ICs who prescribed additional UFH, approximately half (48%) aimed for ACT ≥250 seconds. Factors that influenced post-PCI UFH prescription included vascular access site and concomitant antiplatelet or anticoagulant therapy. CONCLUSIONS The contemporary practice of UFH prescription during PCI and ACT monitoring in ANZ is variable and based on outdated evidence preceding current drug-eluting stents, antiplatelet therapies, and radial-first practice. Current society guideline recommendations lack clarity and agreement, reflecting the quality of the available evidence. Up-to-date clinical trials evaluating UFH prescription and ACT monitoring are needed to optimise clinical outcomes in contemporary PCI procedures.
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Affiliation(s)
- Omar Al-Mukhtar
- Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia. http://www.twitter.com/O_AL_MUKHTAR
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; National Health and Medical Research Council Centre of Research Excellence in Cardiovascular Outcomes Improvement, Curtin University, Perth, WA, Australia
| | - Sidney Lo
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Derek P Chew
- Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Melbourne, Vic, Australia
| | - Andy Yong
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia
| | - Stephen J Nicholls
- Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Melbourne, Vic, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Vic, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Vic, Australia.
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Fujino M, Butters J, Boyes M, Duncan N, Streets F, Sabatini A, Herschtal A, Nelson AJ, Nicholls SJ. Pop-up screening nested within routine community activities unmasks an addressed cardiovascular risk: A pilot study (Gippsland Healthy Heart Study). Aust J Rural Health 2023; 31:1184-1190. [PMID: 37735862 DOI: 10.1111/ajr.13042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/22/2023] [Accepted: 08/31/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVE To evaluate the benefits of a pop-up health screening for cardiovascular risk factors (CVRF) in the Gippsland region, and to assess the acceptability of the screening and to determine whether such a process results in attendance at a general practitioner (GP). PARTICIPANTS Overall, 454 participants over the age of 18 who were residents of the Gippsland region were enrolled. METHODS This is a community-based, observational, prospective cohort study using pop-up screening sites at six retail locations or workplaces, where participants' blood pressure, body weight and lipid profile were measured. The primary outcome was to assess the proportion of participants with at least one unaddressed CVRF (hypertension [blood pressure >140/90 mmHg], overweight and obesity [body mass index >25 kg/m2 ] or hypercholesterolaemia [low-density lipoprotein cholesterol >2.5 mmol/L]). Email surveys were performed after 4 weeks of follow-up. RESULTS Overall, 85.8% (95% confidence interval [CI], 82.1%-88.8%) of participants had at least one unaddressed CVRF. Among the 54 participants who responded to the email survey, 50 participants (92.6% [95% CI, 81.3%-97.6%]) found the screening approach acceptable, and 31 (57.4% [95% CI, 43.3%-70.5%]) considered a discussion with the GP. CONCLUSIONS This study supported the feasibility and effectiveness of pop-up screening to detect CVRF in rural communities.
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Affiliation(s)
- Masashi Fujino
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Julie Butters
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Mark Boyes
- Wesfarmers Health, Melbourne, Victoria, Australia
| | | | | | - Amy Sabatini
- Wesfarmers Health, Melbourne, Victoria, Australia
| | - Alan Herschtal
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adam J Nelson
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
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Tan S, Spear E, Sane N, Chan J, Nelson AJ, Alamgeer M, Nerlekar N, Segelov E, Nicholls SJ. Atherosclerotic Cardiovascular Events in Cancer Patients Treated With Immune Checkpoint Inhibitors: A Retrospective Cohort Study. Heart Lung Circ 2023:S1443-9506(23)04375-5. [PMID: 38042638 DOI: 10.1016/j.hlc.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 10/04/2023] [Accepted: 10/07/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are effective therapies for numerous cancers, but have been associated with atherosclerotic cardiovascular disease (ASCVD). This study aimed to identify predictors for ASCVD events among cancer patients treated with ICIs and the cardiovascular risk factor (CVRF) control of those who developed ASCVD. METHOD A single-centre retrospective study of 366 cancer patients who received ICIs from 2018 to 2020 was performed. Demographic, baseline CVRF, cancer history, and ICI regimen data were obtained from medical records. The primary end point of ASCVD events was defined as myocardial infarction, coronary revascularisation, ischaemic stroke, or acute limb ischaemia. Cox proportional multivariable modelling and competing risks analysis were performed to assess ASCVD predictors. Descriptive analysis was performed to describe CVRF management among those who developed ASCVD events. RESULTS Over a median follow-up of 3.4 years (2.8-4.3), 26 patients (7.1%) experienced 27 ASCVD events (seven myocardial infarction, one coronary revascularisation, 13 ischaemic stroke, and six acute limb ischaemia events). There were 226 (61.8%) cancer-related deaths and no cardiac deaths. History of ASCVD before ICI initiation was independently associated with ASCVD events on traditional Cox modelling (hazard ratio [HR] 4.00; 95% confidence interval [CI] 1.79-8.91; p<0.01) and competing risks analysis (HR 4.23; 95% CI 1.87-9.60; p<0.01). A total of 17 patients developed ASCVD events after ICI cessation (median 1.4 years). Among those with ASCVD events, 12 had prior ASCVD, 16 had hypertension, nine had hypercholesterolaemia, and four had diabetes, and nine were actively smoking. Variable prescription of cardiovascular preventative therapies was noted. CONCLUSIONS History of ASCVD was associated with subsequent ASCVD events among patients treated with ICIs, which could occur even after active treatment was stopped. Identification and aggressive management of modifiable CVRFs should be considered throughout cancer survivorship in patients who received ICI treatment.
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Affiliation(s)
- Sean Tan
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia; Monash Heart, Monash Health, Melbourne, Vic, Australia.
| | - Ella Spear
- Monash Heart, Monash Health, Melbourne, Vic, Australia
| | - Nikhita Sane
- Monash Heart, Monash Health, Melbourne, Vic, Australia
| | - Jasmine Chan
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia; Monash Heart, Monash Health, Melbourne, Vic, Australia
| | - Adam J Nelson
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - Muhammad Alamgeer
- Department of Medical Oncology, Monash Health, Melbourne, Vic, Australia
| | - Nitesh Nerlekar
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia; Monash Heart, Monash Health, Melbourne, Vic, Australia
| | - Eva Segelov
- University of Bern, Bern, Switzerland; Monash University, Melbourne, Vic, Australia
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia; Monash Heart, Monash Health, Melbourne, Vic, Australia
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Hamilton-Craig C, Kostner K, Colquhoun D, Nicholls SJ. Omega-3 fatty acids and cardiovascular prevention: is the jury still out? Intern Med J 2023; 53:2330-2335. [PMID: 38105550 DOI: 10.1111/imj.16283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/01/2023] [Indexed: 12/19/2023]
Abstract
The cardiovascular benefits of omega-3 polyunsaturated fatty acids (O3FA) remain a point of confusion in clinical medicine. Recently two large, randomised trials were published with discordant findings regarding the overall benefits of omega-3 supplementation, resulting in unnecessary confusion and therapeutic nihilism. Epidemiological studies clearly show high intake of fish and measured O3FA (mainly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)) in tissues are inversely associated with cardiovascular events and total mortality. These fatty acids are 'essential' and depend almost entirely on intake with very little production from within the body. The efficacy of supplementation depends on background tissue levels, in contradistinction to drug therapy. Insufficient dosing of omega-3 supplementation using less than 1 g/day and lack of titration to target by failing to measure O3FA levels in the blood may explain these conflicting trial outcomes. We review the current evidence regarding O3FA supplementation and cardiovascular outcomes, describe possible reasons for the discrepant results in the literature including recent controversial data around the mineral oil comparator used in REDUCE-IT and discuss the potential use of the omega-3 index to guide management and optimise supplementation in those at greatest risk.
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Affiliation(s)
- Christian Hamilton-Craig
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Medicine, Griffith University, Sunshine Coast, Queensland, Australia
| | - Karam Kostner
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Director of Cardiology, Mater Hospital, Brisbane, Queensland, Australia
| | - David Colquhoun
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Clinical and Preventive Cardiology, The Wesley Hospital, Brisbane, Queensland, Australia
| | - Stephen J Nicholls
- Victoria Heart Institute, Melbourne, Victoria, Australia
- Faculty of Medicine, Monash University, Melbourne, Victoria, Australia
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Morton JI, Liew D, Nicholls SJ, Ademi Z. Should we continue to subsidise therapeutics with uncertain efficacy? Health economic implications for icosapent ethyl. Eur J Prev Cardiol 2023; 30:1935-1938. [PMID: 36125211 DOI: 10.1093/eurjpc/zwac212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/01/2022] [Accepted: 09/13/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Jedidiah I Morton
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
- School of Public Health and Preventive Medicine, Monash University, Australia
- Baker Heart and Diabetes Institute, Australia
| | - Danny Liew
- Adelaide Medical School, University of Adelaide, Australia
| | | | - Zanfina Ademi
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
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Yu C, Bakshi A, Watts GF, Renton AE, Fulton‐Howard B, Goate AM, Natarajan P, Chasman DI, Robman L, Woods RL, Guymer R, Wolfe R, Thao LTP, McNeil JJ, Tonkin AM, Nicholls SJ, Lacaze P. Genome-Wide Association Study of Cardiovascular Resilience Identifies Protective Variation in the CETP Gene. J Am Heart Assoc 2023; 12:e031459. [PMID: 37929782 PMCID: PMC10727421 DOI: 10.1161/jaha.123.031459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023]
Abstract
Background The risk of atherosclerotic cardiovascular disease (ASCVD) increases sharply with age. Some older individuals, however, remain unaffected despite high predicted risk. These individuals may carry cardioprotective genetic variants that contribute to resilience. Our aim was to assess whether asymptomatic older individuals without prevalent ASCVD carry cardioprotective genetic variants that contribute to ASCVD resilience. Methods and Results We performed a genome-wide association study using a 10-year predicted ASCVD risk score as a quantitative trait, calculated only in asymptomatic older individuals aged ≥70 years without prevalent ASCVD. Our discovery genome-wide association study of N=12 031 ASCVD event-free individuals from the ASPREE (Aspirin in Reducing Events in the Elderly) trial identified 2 independent variants, rs9939224 (P<5×10-8) and rs56156922 (P<10-6), in the CETP (cholesteryl ester transfer protein) gene. The CETP gene is a regulator of plasma high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and lipoprotein(a) levels, and it is a therapeutic drug target. The associations were replicated in the UK Biobank (subpopulation of N=13 888 individuals aged ≥69 years without prevalent ASCVD). Carriers of the identified CETP variants (versus noncarriers) had higher plasma high-density lipoprotein cholesterol levels, lower plasma low-density lipoprotein cholesterol levels, and reduced risk of incident ASCVD events during follow-up. Expression quantitative trait loci analysis predicted the identified CETP variants reduce CETP gene expression across various tissues. Previously reported associations between genetic CETP inhibition and increased risk of age-related macular degeneration were not observed among the 3917 ASPREE trial participants with retinal imaging and genetic data available. Conclusions Common genetic variants in the CETP gene region are associated with cardiovascular resilience during aging. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01038583.
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Affiliation(s)
- Chenglong Yu
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - Andrew Bakshi
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - Gerald F. Watts
- School of MedicineUniversity of Western AustraliaPerthWAAustralia
- Lipid Disorders Clinic, Cardiometabolic Service, Department of CardiologyRoyal Perth HospitalPerthWAAustralia
| | - Alan E. Renton
- Department of Genetics and Genomic SciencesIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Brian Fulton‐Howard
- Department of Genetics and Genomic SciencesIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Alison M. Goate
- Department of Genetics and Genomic SciencesIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Pradeep Natarajan
- Cardiovascular Research Center and Center for Genomic MedicineMassachusetts General HospitalBostonMA
- Program in Population and Medical Genetics and the Cardiovascular Disease InitiativeBroad Institute of Harvard and MITCambridgeMA
- Department of MedicineHarvard Medical SchoolBostonMA
| | - Daniel I. Chasman
- Preventive Medicine Division, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Liubov Robman
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
- Centre for Eye Research AustraliaThe University of Melbourne, Royal Victorian Eye and Ear HospitalMelbourneVICAustralia
| | - Robyn L. Woods
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - Robyn Guymer
- Centre for Eye Research AustraliaThe University of Melbourne, Royal Victorian Eye and Ear HospitalMelbourneVICAustralia
| | - Rory Wolfe
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - Le Thi Phuong Thao
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - John J. McNeil
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - Andrew M. Tonkin
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - Stephen J. Nicholls
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
- Monash Cardiovascular Research Centre, Victorian Heart InstituteMonash UniversityClaytonVICAustralia
| | - Paul Lacaze
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
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Nissen SE, Nicholls SJ, Lincoff AM. Bempedoic Acid for Primary Prevention of Cardiovascular Events-Reply. JAMA 2023; 330:1696-1697. [PMID: 37934221 DOI: 10.1001/jama.2023.17341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Affiliation(s)
- Steven E Nissen
- Cleveland Clinic Center for Clinical Research, Cleveland, Ohio
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Clayton, Victoria, Australia
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Tan S, Spear E, Sane N, Nelson AJ, Nerlekar N, Segelov E, Nicholls SJ. Blood pressure surveillance in cancer patients treated with immune checkpoint inhibitors. J Hum Hypertens 2023; 37:1043-1046. [PMID: 37076569 PMCID: PMC10632129 DOI: 10.1038/s41371-023-00831-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/20/2023] [Accepted: 04/06/2023] [Indexed: 04/21/2023]
Abstract
Immune checkpoint inhibitors (ICI) are cancer therapies that have been associated with increased risk of atherosclerotic cardiovascular disease (ASCVD). Blood pressure (BP) measurements are routinely performed during day oncology center visits for administration of ICI therapy but are often not assessed temporally to screen and monitor hypertension, which could independently increase the risk of ASCVD in cancer survivorship. This study reports the feasibility of using serial BP measurements from routine visits to day oncology center to diagnose and monitor hypertension control in cancer patients receiving ICIs.
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Affiliation(s)
- Sean Tan
- Victorian Heart Institute, Monash University, Melbourne, VIC, Australia.
- Monash Heart, Monash Health, Melbourne, VIC, Australia.
| | - Ella Spear
- Monash Heart, Monash Health, Melbourne, VIC, Australia
| | - Nikhita Sane
- Monash Heart, Monash Health, Melbourne, VIC, Australia
| | - Adam J Nelson
- Victorian Heart Institute, Monash University, Melbourne, VIC, Australia
- Monash Heart, Monash Health, Melbourne, VIC, Australia
| | - Nitesh Nerlekar
- Victorian Heart Institute, Monash University, Melbourne, VIC, Australia
- Monash Heart, Monash Health, Melbourne, VIC, Australia
| | - Eva Segelov
- Monash University, Melbourne, VIC, Australia
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Melbourne, VIC, Australia
- Monash Heart, Monash Health, Melbourne, VIC, Australia
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41
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Abrahams T, Fujino M, Nelson AJ, Nicholls SJ. Impact of PCSK9 inhibitors on coronary atheroma phenotype following myocardial infarction: insights from intravascular imaging. Curr Opin Cardiol 2023; 38:504-508. [PMID: 37751373 DOI: 10.1097/hco.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the impact of combination lipid lowering with statins and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors on coronary atherosclerosis using serial intravascular imaging. RECENT FINDINGS Early studies using intravascular ultrasound established the ability of increasingly intensive lipid lowering to both slow progression and ultimately promote regression of coronary disease. More recent clinical trials that have employed serial imaging with optical coherence tomography have permitted the ability to evaluate the impact of intensive lipid lowering on compositional features associated with plaque vulnerability. In particular, the combination of intensive statin and PCSK9 inhibitor therapy promotes plaque stability in patients following an acute coronary syndrome. SUMMARY More intensive lipid lowering using the combination of statins and PCSK9 inhibitors promote plaque regression in addition to promoting calcification, fibrous cap thickening and reductions in plaque lipid. These plaque-stabilizing effects underscore the benefits of combination therapy on cardiovascular events and highlight the importance of combination lipid-lowering therapy.
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Affiliation(s)
- Timothy Abrahams
- Victorian Heart Institute, Monash University, Clayton, Victoria, Australia
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42
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Sarkies MN, Testa L, Best S, Moullin JC, Sullivan D, Bishop W, Kostner K, Clifton P, Hare D, Brett T, Hutchinson K, Black A, Braithwaite J, Nicholls SJ, Kangaharan N, Pang J, Abhayaratna W, Horton A, Watts GF. Barriers to and Facilitators of Implementing Guidelines for Detecting Familial Hypercholesterolaemia in Australia. Heart Lung Circ 2023; 32:1347-1353. [PMID: 37865587 DOI: 10.1016/j.hlc.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 07/27/2023] [Accepted: 09/06/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Familial hypercholesterolaemia (FH) is a genetic condition that is a preventable cause of premature cardiovascular morbidity and mortality. High-level evidence and clinical practice guidelines support preventative care for people with FH. However, it is estimated that less than 10% of people at risk of FH have been detected using any approach across Australian health settings. The aim of this study was to identify the implementation barriers to and facilitators of the detection of FH in Australia. METHODS Four, 2-hour virtual focus groups were facilitated by implementation scientists and a clinicians as part of the 2021 Australasian FH Summit. Template analysis was used to identify themes. RESULTS There were 28 workshop attendees across four groups (n=6-8 each), yielding 13 barriers and 10 facilitators across three themes: (1) patient related, (2) provider related, and (3) system related. A "lack of care pathways" and "upskilling clinicians in identifying and diagnosing FH" were the most interconnected barriers and facilitators for the detection of FH. CONCLUSIONS The relationships between barriers and facilitators across the patient, provider, and system themes indicates that a comprehensive implementation strategy is needed to address these different levels. Future research is underway to develop a model for implementing the Australian FH guidelines into practice.
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Affiliation(s)
- Mitchell N Sarkies
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.
| | - Luke Testa
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Stephanie Best
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Vic, Australia; Victorian Comprehensive Cancer Centre, Melbourne, Vic, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Vic, Australia
| | - Joanna C Moullin
- School of Public Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - David Sullivan
- Department of Chemical Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Warrick Bishop
- Department of Cardiology, Calvary Cardiac Centre, Calvary Health Care, Hobart, Tas, Australia
| | - Karam Kostner
- Department of Cardiology, Mater Hospital, University of Queensland, Brisbane, Qld, Australia
| | - Peter Clifton
- Department of Endocrinology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - David Hare
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Vic, Australia
| | - Tom Brett
- General Practice and Primary Health Care Research, School of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Karen Hutchinson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Andrew Black
- Department of Cardiology, Royal Hobart Hospital, Hobart, Tas, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | | | - Jing Pang
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
| | - Walter Abhayaratna
- College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
| | - Ari Horton
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, Vic, Australia; Monash Heart and Monash Children's Hospital, Monash Health, Melbourne, Vic, Australia; Monash Genetics, Monash Health, Melbourne, Vic, Australia; Department of Genomic Medicine, The Royal Melbourne Hospital, Parkville, Vic, Australia; Department of Paediatrics, Monash University Clayton, Vic, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia; Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
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Kataoka Y, Kitahara S, Funabashi S, Makino H, Matsubara M, Matsuo M, Omura-Ohata Y, Koezuka R, Tochiya M, Tamanaha T, Tomita T, Honda-Kohmo K, Noguchi M, Maruki M, Kanai E, Murai K, Iwai T, Sawada K, Matama H, Honda S, Fujino M, Yoneda S, Takagi K, Otsuka F, Asaumi Y, Hosoda K, Nicholls SJ, Yasuda S, Noguchi T. The effect of continuous glucose monitoring-guided glycemic control on progression of coronary atherosclerosis in type 2 diabetic patients with coronary artery disease: The OPTIMAL randomized clinical trial. J Diabetes Complications 2023; 37:108592. [PMID: 37741088 DOI: 10.1016/j.jdiacomp.2023.108592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/20/2023] [Accepted: 08/19/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Continuous glucose monitoring (CGM) improves glycemic fluctuation and reduces hypoglycemic risk. Whether CGM-guided glycemic control favorably modulates coronary atherosclerosis in patients with type 2 diabetes (T2DM) remains unknown. METHODS The OPTIMAL trial was a prospective, randomized, single-center trial in which 94 T2DM patients with CAD were randomized to CGM- or HbA1c-guided glycemic control for 48 weeks (jRCT1052180152). The primary endpoint was the nominal change in total atheroma volume (TAV) measured by serial IVUS. The secondary efficacy measure was the nominal change in maxLCBI4mm on near-infrared spectroscopy imaging. RESULTS Among the 94 randomized patients, 82 had evaluable images at 48 weeks. Compared to HbA1c-guided glycemic control, CGM-guided control achieved a greater reduction in %coefficient of variation [-0.1 % (-1.8 to 1.6) vs. -3.3 % (-5.1 to -1.5), p = 0.01] and a greater increase in the duration with glucose between 70 and 180 mg/dL [-1.5 % (-6.0 to 2.9) vs. 6.7 % (1.9 to 11.5), p = 0.02]. TAV increased by 0.11 ± 1.9 mm3 in the HbA1c-guided group and decreased by -3.29 ± 2.00 mm3 in the CGM-guided group [difference = -3.4 mm3 (95%CI: -8.9 to 2.0 mm3), p = 0.22]. MaxLCBI4mm, increased by 90.1 ± 25.6 in the HbA1c-guided group and by 50.6 ± 25.6 in the CGM-guided group (difference = -45.6 (95%CI: -118.1 to 26.7) p = 0.21]. A post-hoc exploratory analysis showed a greater regression of maxLCBI4mm in the CGM-guided group [difference = 20.4 % (95%CI:1.3 to 39.5 %), p = 0.03]. CONCLUSIONS CGM-guided control for 48 weeks did not slow disease progression in T2DM patients with CAD. A greater regression of lipidic plaque under CGM-guided glycemic control in the post-hoc analysis requires further investigation.
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Affiliation(s)
- Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan.
| | - Satoshi Kitahara
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan; Department of Cardiovascular Medicine, Kashiwa Kousei General Hospital, Kashiwa, Japan
| | - Sayaka Funabashi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan; Department of Cardiovascular Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Hisashi Makino
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Masaki Matsubara
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Miki Matsuo
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Yoko Omura-Ohata
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Ryo Koezuka
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Mayu Tochiya
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Tamiko Tamanaha
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Tsutomu Tomita
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Kyoko Honda-Kohmo
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Michio Noguchi
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Maki Maruki
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | - Emi Kanai
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Kota Murai
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Takamasa Iwai
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Kenichiro Sawada
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Hideo Matama
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Masashi Fujino
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Syuichi Yoneda
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Kensuke Takagi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
| | - Kiminori Hosoda
- Division of Diabetes and Lipid Metabolism, National Cerebral & Cardiovascular Center, Suita, Osaka, Japan
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Centre, Suita, Osaka, Japan
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Hosoda H, Kataoka Y, Nicholls SJ, Puri R, Murai K, Kitahara S, Mitsui K, Sugane H, Sawada K, Iwai T, Matama H, Honda S, Takagi K, Fujino M, Yoneda S, Otsuka F, Takamisawa I, Nishihira K, Asaumi Y, Kawai K, Noguchi T. Calcified plaque harboring lipidic materials associates with no-reflow phenomenon after PCI in stable CAD. Int J Cardiovasc Imaging 2023; 39:1927-1941. [PMID: 37378706 PMCID: PMC10589149 DOI: 10.1007/s10554-023-02905-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
Calcified atheroma has been viewed conventionally as stable lesion which less likely increases no-reflow phenomenon. Given that lipidic materials triggers the formation of calcification, lipidic materials could exist within calcified lesion, which may cause no-reflow phenomenon after PCI. The REASSURE-NIRS registry (NCT04864171) employed near-infrared spectroscopy and intravascular ultrasound imaging to evaluate maximum 4-mm lipid-core burden index (maxLCBI4mm) at target lesions containing small (maximum calcification arc < 180°: n = 272) and large calcification (maximum calcification arc ≥ 180°: n = 189) in stable CAD patients. The associations of maxLCBI4mm with corrected TIMI frame count (CTFC) and no-reflow phenomenon after PCI were analyzed in patients with target lesions containing small and large calcification, respectively. No-reflow phenomenon occurred in 8.0% of study population. Receiver-operating characteristics curve analyses revealed that optimal cut-off values of maxLCBI4mm for predicting no-reflow phenomenon were 585 at small calcification (AUC = 0.72, p < 0.001) and 679 at large calcification (AUC = 0.76, p = 0.001). Target lesions containing small calcification with maxLCBI4mm ≥ 585 more likely exhibited a greater CTFC (p < 0.001). In those with large calcification, 55.6% of them had maxLCBI4mm ≥ 400 [vs. 56.2% (small calcification), p = 0.82]. Furthermore, a higher CTFC (p < 0.001) was observed in association with maxLCBI4mm ≥ 679 at large calcification. On multivariable analysis, maxLCBI4mm at large calcification still independently predicted no-reflow phenomenon (OR = 1.60, 95%CI = 1.32-1.94, p < 0.001). MaxLCBI4mm at target lesions exhibiting large calcification elevated a risk of no-reflow phenomenon after PCI. Calcified plaque containing lipidic materials is not necessarily stable lesion, but could be active and high-risk one causing no-reflow phenomenon.
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Affiliation(s)
- Hayato Hosoda
- Department of Cardiovascular Medicine, Chikamori Hospital, Kochi, India
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | | | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Kota Murai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Satoshi Kitahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kentaro Mitsui
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hiroki Sugane
- Department of Cardiovascular Medicine, Chikamori Hospital, Kochi, India
| | - Kenichiro Sawada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takamasa Iwai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hideo Matama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kensuke Takagi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masashi Fujino
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Shuichi Yoneda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Itaru Takamisawa
- Department of Cardiovascular Medicine, Sakakibara Heart Institute, Fuchyu, Tokyo, Japan
| | - Kensaku Nishihira
- Department of Cardiology, Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kazuya Kawai
- Department of Cardiovascular Medicine, Chikamori Hospital, Kochi, India
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
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Kitahara S, Kataoka Y, Miura H, Nishii T, Nishimura K, Murai K, Iwai T, Matama H, Honda S, Fujino M, Yoneda S, Takagi K, Otsuka F, Asaumi Y, Fujino Y, Tsujita K, Puri R, Nicholls SJ, Noguchi T. Characterization of plaque phenotypes exhibiting an elevated pericoronary adipose tissue attenuation: insights from the REASSURE-NIRS registry. Int J Cardiovasc Imaging 2023; 39:1943-1952. [PMID: 37380905 PMCID: PMC10589176 DOI: 10.1007/s10554-023-02907-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 06/19/2023] [Indexed: 06/30/2023]
Abstract
Inflammation has been considered to promote atheroma instability. Coronary computed tomography angiography (CCTA) visualizes pericoronary adipose tissue (PCAT) attenuation, which reflects coronary artery inflammation. While PCAT attenuation has been reported to predict future coronary events, plaque phenotypes exhibiting high PCAT attenuation remains to be fully elucidated. The current study aims to characterize coronary atheroma with a greater vascular inflammation. We retrospectively analyzed culprit lesions in 69 CAD patients receiving PCI from the REASSURE-NIRS registry (NCT04864171). Culprit lesions were evaluated by both CCTA and near-infrared spectroscopy/intravascular ultrasound (NIRS/IVUS) imaging prior to PCI. PCAT attenuation at proximal RCA (PCATRCA) and NIRS/IVUS-derived plaque measures were compared in patients with PCATRCA attenuation ≥ and < -78.3 HU (median). Lesions with PCATRCA attenuation ≥ -78.3 HU exhibited a greater frequency of maxLCBI4mm ≥ 400 (66% vs. 26%, p < 0.01), plaque burden ≥ 70% (94% vs. 74%, p = 0.02) and spotty calcification (49% vs. 6%, p < 0.01). Whereas positive remodeling (63% vs. 41%, p = 0.07) did not differ between two groups. On multivariable analysis, maxLCBI4mm ≥ 400 (OR = 4.07; 95%CI 1.12-14.74, p = 0.03), plaque burden ≥ 70% (OR = 7.87; 95%CI 1.01-61.26, p = 0.04), and spotty calcification (OR = 14.33; 95%CI 2.37-86.73, p < 0.01) independently predicted high PCATRCA attenuation. Of note, while the presence of only one plaque feature did not necessarily elevate PCATRCA attenuation (p = 0.22), lesions harboring two or more features were significantly associated with higher PCATRCA attenuation. More vulnerable plaque phenotypes were observed in patients with high PCATRCA attenuation. Our findings suggest PCATRCA attenuation as the presence of profound disease substrate, which potentially benefits from anti-inflammatory agents.
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Affiliation(s)
- Satoshi Kitahara
- Department of Cardiology, Kashiwa Kousei General Hospital, 617 Shikoda, Kashiwa, Chiba, 277-0862, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Chuo-Ku, Honjo, Kumamoto, 860-8556, Japan
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Hiroyuki Miura
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Tatsuya Nishii
- Department of Radiology, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kota Murai
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Chuo-Ku, Honjo, Kumamoto, 860-8556, Japan
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takamasa Iwai
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hideo Matama
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Chuo-Ku, Honjo, Kumamoto, 860-8556, Japan
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masashi Fujino
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Shuichi Yoneda
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kensuke Takagi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yusuke Fujino
- Department of Cardiology, Kashiwa Kousei General Hospital, 617 Shikoda, Kashiwa, Chiba, 277-0862, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, 631 Blackburn Rd, Clayton, VIC, 3168, Australia
| | - Teruo Noguchi
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Chuo-Ku, Honjo, Kumamoto, 860-8556, Japan
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
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Gray MP, Berman Y, Bottà G, Grieve SM, Ho A, Hu J, Hyun K, Ingles J, Jennings G, Kilov G, Levesque JF, Meikle P, Redfern J, Usherwood T, Vernon ST, Nicholls SJ, Figtree GA. Incorporating a polygenic risk score-triaged coronary calcium score into cardiovascular disease examinations to identify subclinical coronary artery disease (ESCALATE): Protocol for a prospective, nonrandomized implementation trial. Am Heart J 2023; 264:163-173. [PMID: 37364748 DOI: 10.1016/j.ahj.2023.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Identifying and targeting established modifiable risk factors has been a successful strategy for reducing the burden of coronary artery disease (CAD) at the population-level. However, up to 1-in-4 patients who present with ST elevation myocardial infarction do so in the absence of such risk factors. Polygenic risk scores (PRS) have demonstrated an ability to improve risk prediction models independent of traditional risk factors and self-reported family history, but a pathway for implementation has yet to be clearly identified. The aim of this study is to examine the utility of a CAD PRS to identify individuals with subclinical CAD via a novel clinical pathway, triaging low or intermediate absolute risk individuals for noninvasive coronary imaging, and examining the impact on shared treatment decisions and participant experience. TRIAL DESIGN The ESCALATE study is a 12-month, prospective, multicenter implementation study incorporating PRS into otherwise standard primary care CVD risk assessments, to identify patients at increased lifetime CAD risk for noninvasive coronary imaging. One-thousand eligible participants aged 45 to 65 years old will enter the study, which applies PRS to those considered low or moderate 5-year absolute CVD risk and triages those with CAD PRS ≥80% for a coronary calcium scan. The primary outcome will be the identification of subclinical CAD, defined as a coronary artery calcium score (CACS) >0 Agatston units (AU). Multiple secondary outcomes will be assessed, including baseline CACS ≥100 AU or ≥75th age-/sex-matched percentile, the use and intensity of lipid- and blood pressure-lowering therapeutics, cholesterol and blood pressure levels, and health-related quality of life (HRQOL). CONCLUSION This novel trial will generate evidence on the ability of a PRS-triaged CACS to identify subclinical CAD, as well as subsequent differences in traditional risk factor medical management, pharmacotherapy utilization, and participant experience. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12622000436774. Trial was prospectively registered on March 18, 2022. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383134.
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Affiliation(s)
- Michael P Gray
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, NSW, Australia
| | - Yemima Berman
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW, Australia; Department of Clinical Genetics, Royal North Shore Hospital, St Leonards, NSW, Australia
| | | | - Stuart M Grieve
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Imaging and Phenotyping Laboratory, Charles Perkins Centre, University of Sydney, Camperdown, NSW, Australia
| | - Amy Ho
- Our Medical Crows Nest, Crows Nest, NSW, Australia
| | - Jessica Hu
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, NSW, Australia
| | - Karice Hyun
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW, Australia; ANZAC Research Institute, Faculty of Medicine & Health, University of Sydney, Concord West, NSW, Australia
| | - Jodie Ingles
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, Camperdown, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Centre for Population Genomics, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia; Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Garry Jennings
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW, Australia
| | - Gary Kilov
- Launceston Diabetes Clinic, Launceston, TAS, Australia; Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Jean-Frederic Levesque
- NSW Agency for Clinical Innovation, St Leonards, NSW, Australia; Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, Australia
| | - Peter Meikle
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; Department of Cardiovascular Research Translation and Implementation, La Trobe University, Melbourne, VIC, Australia
| | - Julie Redfern
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Sydney School of Health Sciences, Faculty of Medicine & Health, University of Sydney, Camperdown, NSW, Australia
| | - Tim Usherwood
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW, Australia
| | - Stephen T Vernon
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | | | - Gemma A Figtree
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, NSW, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, NSW, Australia.
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47
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Figtree GA, Vernon ST, Harmer JA, Gray MP, Arnott C, Bachour E, Barsha G, Brieger D, Brown A, Celermajer DS, Channon KM, Chew NWS, Chong JJH, Chow CK, Cistulli PA, Ellinor PT, Grieve SM, Guzik TJ, Hagström E, Jenkins A, Jennings G, Keech AC, Kott KA, Kritharides L, Mamas MA, Mehran R, Meikle PJ, Natarajan P, Negishi K, O'Sullivan J, Patel S, Psaltis PJ, Redfern J, Steg PG, Sullivan DR, Sundström J, Vogel B, Wilson A, Wong D, Bhatt DL, Kovacic JC, Nicholls SJ. Clinical Pathway for Coronary Atherosclerosis in Patients Without Conventional Modifiable Risk Factors: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1343-1359. [PMID: 37730292 PMCID: PMC10522922 DOI: 10.1016/j.jacc.2023.06.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/28/2023] [Indexed: 09/22/2023]
Abstract
Reducing the incidence and prevalence of standard modifiable cardiovascular risk factors (SMuRFs) is critical to tackling the global burden of coronary artery disease (CAD). However, a substantial number of individuals develop coronary atherosclerosis despite no SMuRFs. SMuRFless patients presenting with myocardial infarction have been observed to have an unexpected higher early mortality compared to their counterparts with at least 1 SMuRF. Evidence for optimal management of these patients is lacking. We assembled an international, multidisciplinary team to develop an evidence-based clinical pathway for SMuRFless CAD patients. A modified Delphi method was applied. The resulting pathway confirms underlying atherosclerosis and true SMuRFless status, ensures evidence-based secondary prevention, and considers additional tests and interventions for less typical contributors. This dedicated pathway for a previously overlooked CAD population, with an accompanying registry, aims to improve outcomes through enhanced adherence to evidence-based secondary prevention and additional diagnosis of modifiable risk factors observed.
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Affiliation(s)
- Gemma A Figtree
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
| | - Stephen T Vernon
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Jason A Harmer
- Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia; The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia
| | - Michael P Gray
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Eric Bachour
- Consumer Representative, Agile Group Switzerland AG, Zug, Switzerland
| | - Giannie Barsha
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Alex Brown
- National Centre for Indigenous Genomics, Australian National University, Canberra, Australian Capitol Territory, Australia; Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - David S Celermajer
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Keith M Channon
- British Heart Foundation Centre of Research Excellence, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas W S Chew
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - James J H Chong
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Clara K Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Peter A Cistulli
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Department of Respiratory & Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Patrick T Ellinor
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA; Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stuart M Grieve
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Imaging and Phenotyping Laboratory, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Tomasz J Guzik
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom; Department of Internal Medicine and Omicron Medical Genomics Laboratory, Jagiellonian University Medical College, Krakow, Poland
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Alicia Jenkins
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia; Diabetes and Vascular Medicine, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Garry Jennings
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony C Keech
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Katharine A Kott
- Cardiovascular Discovery Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Leonard Kritharides
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia; The ANZAC Research Institute, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognostic Research, Keele University, Keele, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter J Meikle
- Baker Heart and Diabetes Institute, Melbourne, Vicotria, Australia
| | - Pradeep Natarajan
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA; Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Kazuaki Negishi
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Kingswood, New South Wales, Australia
| | - John O'Sullivan
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Precision Cardiovascular Laboratory, University of Sydney, Camperdown, New South Wales, Australia; Heart Research Institute, University of Sydney, Camperdown, New South Wales, Australia
| | - Sanjay Patel
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Heart Research Institute, University of Sydney, Camperdown, New South Wales, Australia
| | - Peter J Psaltis
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, SAHMRI, Adelaide, South Australia, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Julie Redfern
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia; Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Philippe G Steg
- Université de Paris, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials and INSERM Unité 1148, Paris, France
| | - David R Sullivan
- Department of Chemical Pathology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Johan Sundström
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia; Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrew Wilson
- Menzies Centre for Health Policy and Economics, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Dennis Wong
- Monash Cardiovascular Research Centre, Monash University, Clayton, Victoria, Australia; MonashHeart, Monash Health, Clayton, Victoria, Australia
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Jason C Kovacic
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Clayton, Victoria, Australia
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Nicholls SJ, Nissen SE, Fleming C, Urva S, Suico J, Berg PH, Linnebjerg H, Ruotolo G, Turner PK, Michael LF. Muvalaplin, an Oral Small Molecule Inhibitor of Lipoprotein(a) Formation: A Randomized Clinical Trial. JAMA 2023; 330:1042-1053. [PMID: 37638695 PMCID: PMC10463176 DOI: 10.1001/jama.2023.16503] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023]
Abstract
Importance Lipoprotein(a) (Lp[a]) is associated with atherosclerotic disease and aortic stenosis. Lp(a) forms by bonding between apolipoprotein(a) (apo[a]) and apo B100. Muvalaplin is an orally administered small molecule that inhibits Lp(a) formation by blocking the apo(a)-apo B100 interaction while avoiding interaction with a homologous protein, plasminogen. Objective To determine the safety, tolerability, pharmacokinetics, and pharmacodynamic effects of muvalaplin. Design, Setting, and Participants This phase 1 randomized, double-blind, parallel-design study enrolled 114 participants (55 assigned to a single-ascending dose; 59 assigned to a multiple-ascending dose group) at 1 site in the Netherlands. Interventions The single ascending dose treatment evaluated the effect of a single dose of muvalaplin ranging from 1 mg to 800 mg or placebo taken by healthy participants with any Lp(a) level. The multiple ascending dose treatment evaluated the effect of taking daily doses of muvalaplin (30 mg to 800 mg) or placebo for 14 days in patients with Lp(a) levels of 30 mg/dL or higher. Main Outcomes and Measures Outcomes included safety, tolerability, pharmacokinetics, and exploratory pharmacodynamic biomarkers. Results Among 114 randomized (55 in the single ascending dose group: mean [SD] age, 29 [10] years, 35 females [64%], 2 American Indian or Alaska Native [4%], 50 White [91%], 3 multiracial [5%]; 59 in the multiple ascending dose group: mean [SD] age 32 [15] years; 34 females [58%]; 3 American Indian or Alaska Native [5%], 6 Black [10%], 47 White [80%], 3 multiracial [5%]), 105 completed the trial. Muvalaplin was not associated with tolerability concerns or clinically significant adverse effects. Oral doses of 30 mg to 800 mg for 14 days resulted in increasing muvalaplin plasma concentrations and half-life ranging from 70 to 414 hours. Muvalaplin lowered Lp(a) plasma levels within 24 hours after the first dose, with further Lp(a) reduction on repeated dosing. Maximum placebo-adjusted Lp(a) reduction was 63% to 65%, resulting in Lp(a) plasma levels less than 50 mg/dL in 93% of participants, with similar effects at daily doses of 100 mg or more. No clinically significant changes in plasminogen levels or activity were observed. Conclusion Muvalaplin, a selective small molecule inhibitor of Lp(a) formation, was not associated with tolerability concerns and lowered Lp(a) levels up to 65% following daily administration for 14 days. Longer and larger trials will be required to further evaluate safety, tolerability, and effect of muvalaplin on Lp(a) levels and cardiovascular outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT04472676.
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Affiliation(s)
| | - Steven E. Nissen
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Shweta Urva
- Eli Lilly and Company, Indianapolis, Indiana
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Yuvaraj J, Lim E, Vo T, Huynh D, Rocco C, Nerlekar N, Cheng K, Lin A, Dey D, Nicholls SJ, Kangaharan N, Wong DTL. Pericoronary adipose tissue attenuation on coronary computed tomography angiography associates with male sex and Indigenous Australian status. Sci Rep 2023; 13:15509. [PMID: 37726291 PMCID: PMC10509231 DOI: 10.1038/s41598-023-41341-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 08/24/2023] [Indexed: 09/21/2023] Open
Abstract
To evaluate if Indigenous Australians have higher coronary inflammation demonstrated non-invasively using pericoronary adipose tissue attenuation on coronary computed tomography angiography (CCTA). We retrospectively obtained a cohort 54 Indigenous patients age- and sex-matched to 54 non-Indigenous controls (age: 46.5 ± 13.1 years; male: n = 66) undergoing CCTA at the Royal Darwin Hospital and Monash Medical Centre. Patient groups were defined to investigate the interaction of ethnicity and sex: Indigenous + male, Indigenous + female, control + male, control + female. Semi-automated software was used to assess pericoronary adipose tissue attenuation (PCAT-a) and volume (PCAT-v). Males had significantly higher PCAT-a (- 86.7 ± 7.8 HU vs. - 91.3 ± 7.1 HU, p = 0.003) than females. Indigenous patients had significantly higher PCAT-v (1.5 ± 0.5cm3 vs. 1.3 ± 0.4cm3, p = 0.032), but only numerically higher PCAT-a (p = 0.133) than controls. There was a significant difference in PCAT-a and PCAT-v across groups defined by Indigenous status and sex (p = 0.010 and p = 0.030, respectively). Among patients with matching CCTA contrast density, multivariable linear regression analysis showed an independent association between Indigenous status and PCAT-a. Indigenous men have increased PCAT-a in an age- and sex-matched cohort. Male sex is strongly associated with increased PCAT-a. Coronary inflammation may contribute to adverse cardiovascular outcomes in Indigenous Australians, but larger studies are required to validate these findings.
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Affiliation(s)
- Jeremy Yuvaraj
- Monash Cardiovascular Research Centre, Victorian Heart Institute, MonashHeart and Monash University, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Egynne Lim
- Monash Cardiovascular Research Centre, Victorian Heart Institute, MonashHeart and Monash University, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Tony Vo
- Division of Medicine, Royal Darwin Hospital, Tiwi, NT, Australia
- Department of Cardiology, Gold Coast University Hospital, Southport, QLD, Australia
| | - David Huynh
- Division of Medicine, Royal Darwin Hospital, Tiwi, NT, Australia
| | - Cheniqua Rocco
- Division of Medicine, Royal Darwin Hospital, Tiwi, NT, Australia
| | - Nitesh Nerlekar
- Monash Cardiovascular Research Centre, Victorian Heart Institute, MonashHeart and Monash University, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Kevin Cheng
- Monash Cardiovascular Research Centre, Victorian Heart Institute, MonashHeart and Monash University, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Andrew Lin
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, Los Angeles, CA, USA
| | - Damini Dey
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, Los Angeles, CA, USA
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, MonashHeart and Monash University, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | | | - Dennis T L Wong
- Monash Cardiovascular Research Centre, Victorian Heart Institute, MonashHeart and Monash University, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia.
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia.
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50
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Chew NW, Chong B, Kuo SM, Jayabaskaran J, Cai M, Zheng H, Goh R, Kong G, Chin YH, Imran SS, Liang M, Lim P, Yong TH, Liew BW, Chia PL, Ho HH, Foo D, Khoo D, Huang Z, Chua T, Tan JWC, Yeo KK, Hausenloy D, Sim HW, Kua J, Chan KH, Loh PH, Lim TW, Low AF, Chai P, Lee CH, Yeo TC, Yip J, Tan HC, Mamas MA, Nicholls SJ, Chan MY. Trends and predictions of metabolic risk factors for acute myocardial infarction: findings from a multiethnic nationwide cohort. Lancet Reg Health West Pac 2023; 37:100803. [PMID: 37693863 PMCID: PMC10485675 DOI: 10.1016/j.lanwpc.2023.100803] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/21/2023] [Accepted: 05/14/2023] [Indexed: 09/12/2023]
Abstract
Background Understanding the trajectories of metabolic risk factors for acute myocardial infarction (AMI) is necessary for healthcare policymaking. We estimated future projections of the incidence of metabolic diseases in a multi-ethnic population with AMI. Methods The incidence and mortality contributed by metabolic risk factors in the population with AMI (diabetes mellitus [T2DM], hypertension, hyperlipidemia, overweight/obesity, active/previous smokers) were projected up to year 2050, using linear and Poisson regression models based on the Singapore Myocardial Infarction Registry from 2007 to 2018. Forecast analysis was stratified based on age, sex and ethnicity. Findings From 2025 to 2050, the incidence of AMI is predicted to rise by 194.4% from 482 to 1418 per 100,000 population. The largest percentage increase in metabolic risk factors within the population with AMI is projected to be overweight/obesity (880.0% increase), followed by hypertension (248.7% increase), T2DM (215.7% increase), hyperlipidemia (205.0% increase), and active/previous smoking (164.8% increase). The number of AMI-related deaths is expected to increase by 294.7% in individuals with overweight/obesity, while mortality is predicted to decrease by 11.7% in hyperlipidemia, 29.9% in hypertension, 32.7% in T2DM and 49.6% in active/previous smokers, from 2025 to 2050. Compared with Chinese individuals, Indian and Malay individuals bear a disproportionate burden of overweight/obesity incidence and AMI-related mortality. Interpretation The incidence of AMI is projected to continue rising in the coming decades. Overweight/obesity will emerge as fastest-growing metabolic risk factor and the leading risk factor for AMI-related mortality. Funding This research was supported by the NUHS Seed Fund (NUHSRO/2022/058/RO5+6/Seed-Mar/03) and National Medical Research Council Research Training Fellowship (MOH-001131). The SMIR is a national, ministry-funded registry run by the National Registry of Diseases Office and funded by the Ministry of Health, Singapore.
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Affiliation(s)
- Nicholas W.S. Chew
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Bryan Chong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Si Min Kuo
- Policy, Research and Surveillance Division, Health Promotion Board, Singapore
| | | | - Mingshi Cai
- Policy, Research and Surveillance Division, Health Promotion Board, Singapore
| | | | - Rachel Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gwyneth Kong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yip Han Chin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | | | | | | | | | | | | | | | - Zijuan Huang
- Department of Cardiology, National Heart Centre, Singapore
| | - Terrance Chua
- Department of Cardiology, National Heart Centre, Singapore
| | | | | | - Derek Hausenloy
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore
- National Heart Research Institute Singapore, National Heart Centre, Singapore
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - Hui Wen Sim
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Department of Cardiology, Ng Teng Fong General Hospital, Singapore
| | - Jieli Kua
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Department of Cardiology, Ng Teng Fong General Hospital, Singapore
| | - Koo Hui Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Poay Huan Loh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Department of Cardiology, Ng Teng Fong General Hospital, Singapore
| | - Toon Wei Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Adrian F. Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Ping Chai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Chi Hang Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Tiong Cheng Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - James Yip
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Huay Cheem Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Mamas A. Mamas
- Institute of Population Health, University of Manchester, Manchester, UK
- Keele Cardiac Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
| | - Stephen J. Nicholls
- Victorian Heart Institute, Melbourne, Australia
- Monash Heart, Monash Health, Melbourne, Australia
| | - Mark Y. Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
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