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In This Issue of JAMA Cardiology
May 2017


JAMA Cardiol. 2017;2(5):465. doi:10.1001/jamacardio.2016.3644


Cardiovascular and bleeding events after coronary stenting are associated with a high risk of early morbidity and mortality. To assess their effect on late outcomes, Secemsky and coauthors performed a secondary analysis of 11 648 patients enrolled in the multicenter Dual Antiplatelet Therapy Trial, in which all patients received dual antiplatelet drugs for 1 year. Although ischemic events (ie, myocardial infarction, stent thrombosis, or ischemic stroke) were more common than bleeding events (4.1% vs 2.0%, respectively), the annualized mortality rates were similar (27.2 vs 21.5 per 100 person-years). In a commentary, Valgimigli and Gargiulo point out that “choosing between 2 evils occurring at similar frequencies and carrying comparable prognostic implications is still evil.”

Invited Commentary

Author Audio Interview

Despite widespread dissemination of automated external defibrillators, data are limited on frequency and effectiveness of bystander defibrillation. Using the nationwide Danish Cardiac Arrest Registry, Hansen and coauthors identified 18 688 patients with out-of-hospital cardiac arrest. Bystander defibrillation increased in public locations from 1.2% in 2001 to 15.3% in 2012 but remained unchanged in residential locations (from 1.3% to 1.3%) and was associated with higher 30-day out-of-hospital cardiac arrest survival in public compared with in residential locations in 2012 (57.5% vs 25.6%). In a commentary, Callaway emphasizes the need for fewer “bystanders” and more layperson rescuers.

Invited Commentary

Use of non–vitamin K anticoagulants for atrial fibrillation is increasing, but it is unclear whether this is cost-effective. To assess cost and cost-effectiveness of apixaban therapy compared with warfarin therapy in the US health care system, Cowper and coauthors performed a patient-level analysis of resource use in 18 201 patients (3417 in the United States) in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation Trial. Including the cost of anticoagulation and monitoring, the incremental cost of achieving greater life expectancy with apixaban (7.94 vs 7.54 quality-adjusted life-years) was within accepted US norms ($53 925 per quality-adjusted life-year). Hlatky concludes in a commentary that the clinical outcomes were improved sufficiently in this analysis to provide reasonable value in the US system.

Invited Commentary

The safety of achieving long-term very low low-density lipoprotein cholesterol (LDL-C) levels with drug therapy is unknown. To assess safety and clinical efficacy of achieving very low (<30 mg/dL) levels of LDL-C, Giugliano and coauthors studied 15 281 patients enrolled in the Improved Reduction of Outcomes: Vytorin Efficacy International Trial over a 6-year period. After multivariate adjustment, there was no association between achieved LDL-C level and any of 9 prespecified safety events. The adjusted risk of the primary efficacy composite (cardiovascular death, major coronary events, or stroke) was significantly lower in patients achieving an LDL-C level less than 30 mg/dL at 1 month compared with those with a level of 70 mg/dL or greater. These data provide reassurance regarding longer-term safety and efficacy of continuing intensive lipid-lowering therapy in higher-risk patients resulting in very low LDL-C levels.