MARCH 5, 2019
VOLUME 73
NUMBER 8
CONTENTS
ORIGINAL INVESTIGATIONS
JACC CME/MOC/ECME is available online.
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Articles have accompanying
audio accessible online at
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Impact of Procedure Time on Outcomes of Thrombectomy for Stroke
879Ali Alawieh, Jan Vargas, Kyle M. Fargen, E. Farris Langley, Robert M. Starke,Reade De Leacy, Rano Chatterjee, Ansaar Rai, Travis Dumont, Peter Kan,David McCarthy, Fábio A. Nascimento, Jasmeet Singh, Lukas Vilella, Aquilla Turk,Alejandro M. Spiotta
Although successful endovascular thrombectomy for acute ischemic stroke has high efficacy in
improving functional outcomes, the decision to abort a long procedure remains a challenge. Using
a multicenter cohort of 1,359 patients undergoing endovascular thrombectomy for stroke, the
authors investigated the risks and outcomes associated with extending thrombectomy procedure
times. Extending procedure times beyond 30 min is associated with reduced rates of functional
independence, an exponential increase in risk of complications and hemorrhage, and minimal
improvement in recanalization success rates. Faster recanalization was achieved using aspiration
than with stent retriever thrombectomy. Posterior circulation strokes were more sensitive to longer
procedure times.
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n EDITORIAL COMMENT
Endovascular Thrombectomy Procedure Time and OtherPredictors of Futility in Acute Ischemic Stroke Interventions
891
Nestor R. Gonzalez
Stress Testing Versus CT Angiography in Patients With Diabetes andSuspected Coronary Artery Disease
893
Abhinav Sharma, Adrian Coles, Nishant K. Sekaran, Neha J. Pagidipati, Michael T. Lu,Daniel B. Mark, Kerry L. Lee, Hussein R. Al-Khalidi, Udo Hoffmann, Pamela S. Douglas
The optimal noninvasive test for patients with diabetes and stable symptoms of coronary artery
disease (CAD) is unknown. The authors compared cardiovascular (CV) outcomes in patients with
diabetes (n = 1,908 [21%]) and without diabetes (n = 7,058 [79%]) based on their randomization
to computed tomographic angiography (CTA) or functional testing in the PROMISE (Prospective
Multicenter Imaging Study for Evaluation of Chest Pain) trial. In patients with diabetes, a CTA
strategy resulted in a lower risk of CV death/myocardial infarction than functional testing (adjusted
hazard ratio: 0.38; 95% confidence interval: 0.18 to 0.79; p = 0.01). This result was not seen in
patients without diabetes. CTA may be considered as the initial diagnostic strategy among stable
patients with diabetes and symptoms suggestive of CAD.
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n EDITORIAL COMMENT
Coronary CT Angiography in New-Onset Stable Chest Pain:Time for U.S. Guidelines to Be NICEr
903
Michael J. Blaha, Miguel Cainzos-Achirica
CONTENTSMARCH 5, 2019 VOLUME 73, NUMBER 8
Interval From Initiation of Prasugrel to Coronary Angiography inPatients With Non–ST-Segment Elevation Myocardial Infarction
906
Johanne Silvain, Tomasz Rakowski, Benoit Lattuca, Zhenyu Liu, Leonardo Bolognese,Patrick Goldstein, Christian Hamm, Jean-Francois Tanguay, Jur ten Berg, Petr Widimsky,Debra Miller, Jean-Jacques Portal, Jean-Philippe Collet, Eric Vicaut, Gilles Montalescot,Dariusz Dudek, for the ACCOAST Investigators
In the ACCOAST (A Comparison of Prasugrel at PCI or Time of Diagnosis of Non-ST Elevation
Myocardial Infarction) trial, the prasugrel pre-treatment strategy versus placebo was not
associated with improved ischemic outcome in non–ST-segment elevation myocardial infarction
(MI). The authors evaluated whether this was related to a too-short duration of pre-treatment and
assessed the effect of pre-treatment duration with prasugrel on ischemic and bleeding outcomes.
They found that neither the primary efficacy outcome of cardiovascular death, MI, stroke, urgent
revascularization, or glycoprotein IIb/IIIa inhibitor bailout use nor the safety outcome of all
coronary artery bypass graft or non-coronary artery bypass graft TIMI (Thrombolysis In Myocardial
Infarction) major bleeding differed between the quartiles of pre-treatment duration (p = 0.17 and
p = 0.37 for interaction, respectively).
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n EDITORIAL COMMENT
Pre-Treatment With Oral P2Y12 Inhibitors in Acute Coronary SyndromesWithout ST-Segment Elevation: The Saga Continues
915
Davide Capodanno, Dominick J. Angiolillo
Direct Oral Anticoagulants in Patients WithNonvalvular Atrial Fibrillation and Low Body Weight
919
So-Ryoung Lee, Eue-Keun Choi, Chan Soon Park, Kyung-Do Han, Jin-Hyung Jung,Seil Oh, Gregory Y.H. Lip
This study compared direct oral anticoagulants (DOACs) with warfarin in patients with atrial
fibrillation with low body weight (#60 kg) (n = 14,013 taking DOACs and n = 7,576 taking
warfarin). In this real-world Asian atrial fibrillation population with low body weight, DOACs were
associated with lower risks of ischemic stroke, major bleeding, and all-cause death than warfarin.
These results were consistently observed in patients with extremely low body weight (<50 kg).
Both regular and reduced doses of DOACs had an improved net clinical benefit compared with
warfarin; regular doses of DOACs showed comparable results as reduced doses of DOACs in both
effectiveness and safety.
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n EDITORIAL COMMENT
Low Body Weight and Prescribing DOACs in Atrial Fibrillation
932Freek W.A. Verheugt
CONTENTSMARCH 5, 2019 VOLUME 73, NUMBER 8
Clinical Course of Patients With Worsening Heart Failure WithReduced Ejection Fraction
935
Javed Butler, Mei Yang, Massimiliano Alfonzo Manzi, Gregory P. Hess,Mahesh J. Patel, Thomas Rhodes, Michael M. Givertz
Assessment of incidence, clinical characteristics, treatment, and outcomes of patients with worsening
heart failure and reduced ejection fraction (HFrEF) who develop worsening heart failure (HF) using
linked registry-based and claims-based data show that 1 in 6 patients with HFrEF will develop
worsening HF within 18 months of HF diagnosis. These patients are at a high risk for adverse
outcomes. A significant proportion of these patients were not receiving recommended HF therapy,
and those who were on drug therapy were not on target doses before or after development of
worsening HF. Patients with worsening HF have significant unmet medical need for novel
treatments and optimized use of existing guideline-directed therapy.
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n EDITORIAL COMMENT
Optimizing Medical Therapy in Chronic Worsening HFrEF: A Long Way to Go
945Adam P. Bress, Jordan B. King
THE PRESENT
AND FUTURE
JACC STATE-OF-
THE-ART REVIEW
Nonalcoholic Fatty Liver Disease and the Heart:
JACC State-of-the-Art Review
948
Eric P. Stahl, Devinder S. Dhindsa, Suegene K. Lee, Pratik B. Sandesara,Naga P. Chalasani, Laurence S. Sperling
Nonalcoholic fatty liver disease is associated with cardiovascular disease through multiple
pathophysiological mechanisms. The aim of this comprehensive review is to examine this
association, discuss the overlapping management approaches, and discuss future therapies.
JACC REVIEW TOPIC
OF THE WEEK
PCI and CABG for Treating Stable Coronary Artery Disease:JACC Review Topic of the Week
964
Torsten Doenst, Axel Haverich, Patrick Serruys, Robert O. Bonow, Pieter Kappetein,Volkmar Falk, Eric Velazquez, Anno Diegeler, Holger Sigusch
Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) treat stable
coronary artery disease by revascularization, but only CABG may prolong life. Viability or ischemia
detection to guide revascularization are unable to accurately predict the treatment effects of
CABG or PCI, questioning revascularization as a mechanism improving survival. However,
preventing myocardial infarction may improve survival. Comparisons of CABG and PCI
demonstrating improved survival with CABG always demonstrate infarct reduction. Because the
majority of infarcts are generated by non–flow-limiting stenoses, PCI may not affect infarcts
(treating only flow-limiting lesions), but CABG may avoid infarcts (providing flow distal to vessel
occlusions). The evidence is reviewed here.
CONTENTSMARCH 5, 2019 VOLUME 73, NUMBER 8
JACC INTERNATIONAL
10-Year Heart Failure Outcomes From Nurse-Driven Clinics inRural Sub-Saharan Africa977
Lauren A. Eberly, Emmanuel Rusingiza, Paul H. Park, Gedeon Ngoga,Symaque Dusabeyezu, Francis Mutabazi, Cyprien Gahamanyi, Evariste Ntaganda,Gene F. Kwan, Gene Bukhman
LETTERS
Aortic Stiffness in Patients With Inflammatory Bowel Disease Reduced AfterAnti-Tumor Necrosis Factor Therapy981
Luca Zanoli, Gaetano Inserra, Maria Cappello, Kadir Ozturk, Pietro Castellino
Takotsubo Recurrence: Morphological Types and Triggers andIdentification of Risk Factors
982
Ken Kato, Davide Di Vece, Victoria L. Cammann, Jozef Micek, Konrad A. Szawan,Beatrice Bacchi, Thomas F. Lüscher, Frank Ruschitzka, Jelena R. Ghadri,Christian Templin, on behalf of the InterTAK Collaborators
Intravenous Drug Use–Associated Endocarditis Complicating Research ofAntibiotic Prophylaxis and Guideline Recommendations
984
Jonathan J. Eddinger
ReplyMartin H. Thornhill, Mark J. Dayer, Vivian H. Chu, Patrick T. O’Gara, Larry M. Baddour
CORRECTION
987