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In This Issue of JAMA Cardiology
February 2020


JAMA Cardiol. 2020;5(2):119. doi:10.1001/jamacardio.2019.3439


Whether radial access or femoral access for primary percutaneous coronary intervention is associated with survival in patients with ST-segment elevation myocardial infarction (STEMI) remains controversial. Le May and coauthors enrolled 2292 patients with STEMI in a randomized clinical trial at 5 percutaneous coronary intervention centers in Canada. The trial was stopped early following a futility analysis. The primary outcome, 30-day all-cause mortality, did not differ between patients assigned to radial access vs femoral access (17 of 1136 [1.5%] vs 15 of 1156 [1.3%], respectively), and there were no differences in rates of reinfarction, stroke, and bleeding. In an Invited Commentary, Sweis places these results in context and notes that the weight of the evidence favors a radial-first approach.

Invited Commentary

The association of longitudinal changes in albuminuria through young adulthood, measured by urine albumin-to-creatinine ratio (UACR) levels, with myocardial structure and function later in life remains unclear. Patel and coauthors studied trajectories of UACR in 2647 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study from the year 10 to the year 30 examinations. Compared with individuals with stable UACR levels, those with increasing UACR levels over 20 years had greater left ventricular (LV) mass after adjustment for clinical variables and baseline UACR level. Significant differences were also noted in LV longitudinal strain, e′ tissue velocities, and estimated LV filling pressures.

The best noninvasive test for older patients with stable symptoms suggestive of coronary artery disease (CAD) at risk of cardiovascular events remains unknown. Lowenstern and coauthors performed a prespecified analysis of 8966 individuals enrolled in the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) study who were randomized to noninvasive testing with coronary computed tomographic angiography or functional testing. A positive functional test result was not associated with cardiovascular death/myocardial infarction in patients younger than 65 years, but it was among older patients. Conversely, a positive anatomic test result was associated with cardiovascular death/myocardial infarction among patients younger than 65 years but not among older patients.

Data are limited comparing the strategies of in-hospital vs postdischarge initiation of sacubitril/valsartan among stabilized patients with acute decompensated heart failure (HF). DeVore and coauthors performed a secondary analysis of 881 patients enrolled in the PIONEER-HF trial, who were observed for an additional 4 weeks in an open-label study following the 8-week termination of the trial. In patients randomized to sacubitril/valsartan who continued receiving sacubitril/valsartan, N-terminal pro–B-type natriuretic peptide levels declined −17.2% from week 8 to 12. N-terminal pro–B-type natriuretic peptide levels declined to a greater extent (−37.4%) in those randomized to enalapril who were switched to sacubitril/valsartan after the week 8 visit. In an Invited Commentary, Wilcox states that early implementation of sacubitril/valsartan in the inpatient or postdischarge setting has the potential to improve HF outcomes.

Invited Commentary

Continuing Medical Education