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In This Issue of JAMA Cardiology
January 2017


JAMA Cardiol. 2017;2(1):1. doi:10.1001/jamacardio.2016.3624


Mortality from coronary artery disease is declining, and women are underrepresented in previous exercise test-based risk models. Cremer and coauthors investigated whether estimates of all-cause mortality were enhanced with sex-specific risk scores in the current era. The study included 109 155 patients aged 45 to 64 years who underwent stress testing at the Cleveland Clinic and Henry Ford Hospital. The patients were randomly distributed into derivation and validation cohorts and observed for a mean of 7 years. Sex-specific risk scores had higher C statistics for all-cause mortality (women, 0.79; men, 0.81) than those using other tools, with high net reclassification. In a commentary, Krishnaswami and coauthors discuss the importance of objective prognostication with clinical prediction models and the challenge in improving outcomes while streamlining workflow.

Invited Commentary

Despite guideline recommendations for high-intensity statin therapy in patients with established atherosclerotic cardiovascular disease (ASCVD), statin therapy in general and high-intensity statin therapy in particular are underused in such patients. Rodriguez and coauthors studied 509 766 eligible patients with ASCVD aged 21 to 84 years in the Veterans Affairs healthcare system and reported a graded association between statin intensity and mortality, with 1-year mortality rates of 4.0% with high-intensity, 4.8% with moderate-intensity, 5.7% with low-intensity, and 6.6% with no statin therapy. The adjusted hazard ratio for mortality was 0.91 for those receiving high-intensity vs moderate-intensity statin therapy. These data support the use of maximal doses of statins to enhance survival for patients with ASCVD.

Editor’s Note

Limited data link objective physical activity patterns, fitness, sleep, and cardiovascular health. McConnell and coauthors assessed the feasibility of using mobile devices to assess activity patterns and their association with life satisfaction and perception of disease risk. Using a mobile application, 48 968 self-selected individuals (median age, 36 years; 82% male) from all 50 states consented, of whom 82% uploaded data, 42% completed 4 of 7 days, and 9% completed all 7 days. In a commentary, Spring addresses the potential and challenges of mobile technology in population health research, including the need to reach a broader population and maximize sustainability.

Invited Commentary and Editor’s Note

Guidelines recommend the use of mineralocorticoid receptor antagonists (MRAs) in patients with symptomatic heart failure and reduced ejection fraction, but MRAs increase the risk of hyperkalemia. In a secondary analysis of 8399 patients with chronic heart failure in the PARADIGM Trial, Desai and coauthors reported that the development of hyperkalemia was similar in those randomized to 97/103 mg of sacubitril/valsartan twice daily versus 10 mg of enalapril twice daily (in addition to guideline-directed medical therapy) but that severe hyperkalemia was more common in patients assigned to enalapril. In a commentary, Ezekowitz discusses that more work is necessary to better characterize those at risk of hyperkalemia beyond relatively crude estimates based on history of diabetes or chronic kidney disease to aid in the judicious use of MRAs.

Invited Commentary