J OCTOBER 19, 2010 VOLUME 56, NO. 17 JOURNAL of the AMERICAN COLLEGE of CARDIOLOGY Inside This Issue JACC WHITE PAPER D S S r p l i c 4 T i I R D S S P i l c o v d c s w ACC WHITE PAPER 1357Stent Thrombosis avid R. Holmes, Jr, Dean J. Kereiakes, Scot Garg, Patrick W. Serruys, Gregory J. Dehmer, tephen G. Ellis, David O. Williams, Takeshi Kimura, David J. Moliterno tent thrombosis (ST) with either drug-eluting stents (DES) or bare-metal stents (BMS) emains catastrophic and, although infrequent, modifies the risk-benefit equation of ercutaneous coronary intervention. This White Paper by Holmes and colleagues reviews the iterature regarding ST and divides the risk factors into the following categories: 1) the stent, ncluding its geometry, polymer, and drug; 2) the patient, including clinical presentation and omorbidities; 3) the procedure, including residual dissection or incomplete expansion; and ) the extent and duration of antiplatelet therapy and the patient response to this therapy. he authors hope that improved understanding of these risk factors will facilitate the dentification of optimal preventive strategies. CLINICAL RESEARCH NTERVENTIONAL CARDIOLOGY 1366egistry Shows Similar Outcomes at 5 to 10 Years for CABG or PCI for Left Main Disease uk-Woo Park, Young-Hak Kim, Sung-Cheol Yun, Jong-Young Lee, Won-Jang Kim, Soo-Jin Kang, eung-Whan Lee, Cheol-Whan Lee, Jae-Joong Kim, Suk-Jung Choo, Cheol-Hyun Chung, Jae-Won Lee, eong-Wook Park, Seung-Jung Park ark and colleagues evaluated the long-term safety and effectiveness of percutaneous coronary ntervention (PCI) compared with coronary artery bypass grafting (CABG) for unprotected eft main coronary artery (LMCA) disease. In the 10-year follow-up cohort of ontemporaneous bare-metal stents or CABG, there were no differences in the adjusted risks f death or the composite of death, Q-wave myocardial infarction, or stroke, while target essel revascularization (TVR) was 10 times more likely. Similarly, for the 5-year follow-up of rug-eluting stents (DES) or CABG, there were no significant differences for death or the omposite outcome, but the rate of TVR was 6 times higher in the DES group. PCI with tent implantation has similar long-term mortality and major adverse event rates compared ith CABG, but higher rates of TVR. (continued on page A-30) http://linkinghub.elsevier.com/retrieve/pii/S0735109710034534 http://linkinghub.elsevier.com/retrieve/pii/S0735109710034558 OCTOBER 19, 2010 (continued) A-30 A J E W s A ( c a m u o H V J T b f E A m f T t E CUTE CORONARY SYNDROMES 1376Prior Aspirin Use Does Not Increase Risk of ACS onathan D. Rich, Christopher P. Cannon, Sabina A. Murphy, Jie Qin, Robert P. Giugliano, ugene Braunwald hile aspirin is clearly beneficial for the treatment of an acute coronary syndrome (ACS), ome studies have suggested worse outcomes in those who were taking aspirin prior to their CS. Rich and colleagues evaluated 66,443 ACS patients from a merged database of TIMI Thrombolysis In Myocardial Infarction) trials. Prior aspirin users were older, had more oronary risk factors, and were more likely to have previously been diagnosed with coronary rtery disease. Unadjusted analyses showed worse outcomes for aspirin users, but after ultivariate analysis, there was no difference in total mortality at day 30 or by the last follow- p visit. Prior aspirin use identifies patients with greater baseline risk but does not affect utcomes in ACS patients. EART RHYTHM DISORDERS 1386Optical Mapping of the Human Sinus Node adim V. Fedorov, Alexey V. Glukhov, Roger Chang, Geran Kostecki, Hyuliya Aferol, William J. Hucker, oseph P. Wuskell, Leslie M. Loew, Richard B. Schuessler, Nader Moazami, Igor R. Efimov he site of origin and pattern of excitation within the human sinoatrial node (SAN) has not een directly mapped. Fedorov and colleagues optically mapped the SAN in preparations rom human hearts and reconstructed the 3-dimensional structure of the SAN with histology. xcitation originated in the middle of the SAN, and then slowly spread within the SAN. fter a conduction delay within the SAN, the atrial myocardium was excited via superior, iddle, and/or inferior sinoatrial exit pathways. The SAN structure was functionally insulated rom the atrium by connective tissue, fat, and coronary arteries, except for these exit pathways. his study maps the pattern of excitation within the human SAN, and the exit pathways into he right atrium. ditorial Comment: Miguel Valderrábano, Amish S. Dave, p. 1395 (continued on page A-31) http://linkinghub.elsevier.com/retrieve/pii/S0735109710034522 http://linkinghub.elsevier.com/retrieve/pii/S0735109710034571 http://linkinghub.elsevier.com/retrieve/pii/S073510971003456X OCTOBER 19, 2010 (continued) A-31 I R N J E d b T F f 6 h h I S F J E 1 d o s o p E P H Z T c d d a a p E MAGING OF CORONARY CALCIUM 1397CAC Score Improves Coronary Risk Prediction aimund Erbel, Stefan Möhlenkamp, Susanne Moebus, Axel Schmermund, Nils Lehmann, Andreas Stang, ico Dragano, Dietrich Grönemeyer, Rainer Seibel, Hagen Kälsch, Martina Bröcker-Preuss, Klaus Mann, ohannes Siegrist, Karl-Heinz Jöckel, for the Heinz Nixdorf Recall Study Investigative Group rbel and colleagues used data from over 4,000 subjects without known coronary artery isease at baseline to determine net reclassification improvement (NRI) and risk prediction ased on coronary artery calcification (CAC) scoring in comparison to traditional risk factors. he baseline risk was categorized into low, intermediate, and high according to the ramingham risk score (FRS) or Adult Treatment Panel III guidelines, and subjects were ollowed for 5 years. Reclassifying FRS 10-year intermediate-risk (defined as 10% to 20% and % to 20%) subjects with CAC �100 to the low-risk category and with CAC �400 to the igh-risk category yielded an NRI of 22% and 31%, respectively. CAC scoring results in a igh reclassification rate in the intermediate-risk cohort. MAGING OF CORONARY CALCIUM 1407CAC Score and 10-Year Coronary Risk uzette E. Elias-Smale, Rozemarijn Vliegenthart Proença, Michael T. Koller, Maryam Kavousi, rank J. A. van Rooij, Myriam G. Hunink, Ewout W. Steyerberg, Albert Hofman, Matthijs Oudkerk, acqueline C. M. Witteman lias-Smale and colleagues followed over 2,000 subjects with a mean age of 70 years for 0 years to examine the effect of coronary calcium on the risk of 10-year hard coronary heart isease (CHD) events. A total of 52% of subjects initially classified as intermediate-risk based n their Framingham risk scores were reclassified by means of coronary artery calcium (CAC) core: to high-risk for a CAC �615 and to low-risk for CAC �50. In a general population f elderly persons at intermediate CHD risk, CAC scoring is a powerful method to reclassify ersons into more appropriate risk categories. ditorial Comment: Daniel Duprez, p. 1415 RE-CLINICAL RESEARCH 1418Doxycycline Improves Survival in a Mouse Model of Cardiac Proteinopathy anqiao Zheng, Mingxin Tang, Qingwen Zheng, Asangi R. K. Kumarapeli, Kathleen M. Horak, ongwen Tian, Xuejun Wang ransgenic (TG) cardiac overexpression of missense mutant �B-crystallin (CryABR120G) auses aberrant protein aggregation and cardiomyopathy, recapitulating key features of human esmin-related cardiomyopathy (DRC). Zheng and colleagues treated TG mice with either oxycycline or placebo. Doxycycline treatment significantly attenuated cardiac hypertrophy nd improved survival. In cell culture, doxycycline suppressed the formation of both protein ggregates and oligomers. Doxycycline decreases the toxicity of aberrant CryABR120G roduction and may be useful for human DRC. ditorial Comment: Francisco Villarreal, Wilbur Y. W. Lew, p. 1427 http://linkinghub.elsevier.com/retrieve/pii/S0735109710034583 http://linkinghub.elsevier.com/retrieve/pii/S0735109710034546 http://linkinghub.elsevier.com/retrieve/pii/S0735109710034510 http://linkinghub.elsevier.com/retrieve/pii/S0735109710035072 http://linkinghub.elsevier.com/retrieve/pii/S0735109710035023