MARCH 5, 2019

VOLUME 73

NUMBER 8

CONTENTS

ORIGINAL INVESTIGATIONS

JACC CME/MOC/ECME is available online.

Go to http://www.acc.org/jacc-journals-cme.

Articles have accompanying

audio accessible online at

www.onlineJACC.org.

Impact of Procedure Time on Outcomes of Thrombectomy for Stroke

879

Ali 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.

SEE ADDITIONAL CONTENT ONLINE

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

932

Freek 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

945

Adam 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 Africa

977

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 Therapy

981

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