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New England Journal of Medicine

Structural Iatrogenesis — A 43-Year-Old Man with “Opioid Misuse”
New England Journal of Medicine, Volume 380, Issue 8, Page 701-704, February 2019.
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Don’t Ruin My Life — Aging and Driving in the 21st Century
New England Journal of Medicine, Volume 380, Issue 8, Page 705-707, February 2019.
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Endings, Beginnings
New England Journal of Medicine, Volume 380, Issue 8, Page 708-709, February 2019.
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Apixaban to Prevent Venous Thromboembolism in Patients with Cancer
New England Journal of Medicine, Volume 380, Issue 8, Page 711-719, February 2019.
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Heartbeat: Risk stratification for asymptomatic severe aortic stenosis
The recommendation in current guidelines that aortic valve replacement (AVR) be performed in adults with symptomatic severe aortic stenosis (AS) is based on solid evidence. However, it is unclear whether adults with asymptomatic severe AS also should be considered for elective AVR. This uncertainty is based on several considerations including the difficulty in recognising that symptoms are present and might be due to AS in older adults who often have multiple comorbidities, the concern that waiting for symptoms might be associated with irreversible cardiac changes, and the (although small) risk of sudden death. In addition, perhaps it makes sense to perform AVR before the patient is older and sicker, given the inevitable progression to symptoms once severe AS is present. On the other hand, both surgical and transcatheter AVR are associated with mortality and morbidity and the bioprosthetic valve is subject to deterioration, starting at the time of implantation. ...
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Digoxin for rheumatic heart disease: a cautious future for a drug from the past?
Rheumatic heart disease (RHD) is the late sequelae of inadequately treated group A streptococcal pharyngeal infections, leading to acute rheumatic fever, a multisystem immune response that often culminates in valvular damage and ultimately heart failure (HF).1 While advanced rheumatic valvular disease is ideally treated with interventional procedures (surgical or percutaneous), the reality is that access to these procedures is severely constrained in many RHD-endemic areas, limiting patients to medical management for symptom control.2 There are very limited data on the best practices for medical management of RHD, with most recommendations drawn from what is known from the general literature on HF, supraventricular arrhythmias and valvular heart disease. This is problematic because the population of patients with RHD is both younger and less likely to have secondary cardiac risk (such as coronary artery disease and hypertension) as compared with the general HF and valvular heart disease communities. In...
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JACC Instructions for Authors
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Dual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary Stenting
AbstractBackground Complex percutaneous coronary intervention (PCI) is associated with higher ischemic risk, which can be mitigated by long-term dual antiplatelet therapy (DAPT). However, concomitant high bleeding risk (HBR) may be present, making it unclear whether short- or long-term DAPT should be prioritized. Objectives This study investigated the effects of ischemic (by PCI complexity) and bleeding (by PRECISE-DAPT [PREdicting bleeding Complications in patients undergoing stent Implantation and SubsequEnt Dual AntiPlatelet Therapy] score) risks on clinical outcomes and on the impact of DAPT duration after coronary stenting. Methods Complex PCI was defined as ≥3 stents implanted and/or ≥3 lesions treated, bifurcation stenting and/or stent length >60 mm, and/or chronic total occlusion revascularization. Ischemic and bleeding outcomes in high (≥25) or non-high (<25) PRECISE-DAPT strata were evaluated based on randomly allocated duration of DAPT. Results Among 14,963 patients from 8 randomized trials, 3,118 underwent complex PCI and experienced a higher rate of ischemic, but not bleeding, events. Long-term DAPT in non-HBR patients reduced ischemic events in both complex (absolute risk difference: –3.86%; 95% confidence interval: –7.71 to +0.06) and noncomplex PCI strata (absolute risk difference: –1.14%; 95% confidence interval: –2.26 to –0.02), but not among HBR patients, regardless of complex PCI features. The bleeding risk according to the Thrombolysis In Myocardial Infarction scale was increased by long-term DAPT only in HBR patients, regardless of PCI complexity. Conclusions Patients who underwent complex PCI had a higher risk of ischemic events, but benefitted from long-term DAPT only if HBR features were not present. These data suggested that when concordant, bleeding, more than ischemic risk, should inform decision-making on the duration of DAPT.
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Optimizing DAPT Duration in High-Risk Patients After Coronary Stent Implantation: Bleeding Risk Takes It All
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Post-Procedural Bivalirudin Infusion at Full or Low Regimen in Patients With Acute Coronary Syndrome
AbstractBackground The value of prolonged bivalirudin infusion after percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) patients with or without ST-segment elevation remains unclear. Objectives The purpose of this study was to assess efficacy and safety of a full or low post-PCI bivalirudin regimen in ACS patients with or without ST-segment elevation. Methods The MATRIX program assigned bivalirudin to patients without or with a post-PCI infusion at either a full (1.75 mg/kg/h for ≤4 h) or reduced (0.25 mg/kg/h for ≤6 h) regimen at the operator’s discretion. The primary endpoint was the 30-day composite of urgent target-vessel revascularization, definite stent thrombosis, or net adverse clinical events (composite of all-cause death, myocardial infarction, or stroke, or major bleeding). Results Among 3,610 patients assigned to bivalirudin, 1,799 were randomized to receive and 1,811 not to receive a post-PCI bivalirudin infusion. Post-PCI full bivalirudin was administered in 612 (ST-segment elevation myocardial infarction [STEMI], n = 399; non–ST-segment elevation acute coronary syndromes [NSTE-ACS], n = 213), whereas the low-dose regimen was administered in 1,068 (STEMI, n = 519; NSTE-ACS, n = 549) patients. The primary outcome did not differ in STEMI or NSTE-ACS patients who received or did not receive post-PCI bivalirudin. However, full compared with low bivalirudin regimen remained associated with a significant reduction of the primary endpoint after multivariable (rate ratio: 0.21; 95% CI: 0.12 to 0.35; p < 0.001) or propensity score (rate ratio: 0.16; 95% CI: 0.09 to 0.26; p < 0.001) adjustment. Full post-PCI bivalirudin was associated with improved outcomes consistently across ACS types compared with the no post-PCI infusion or heparin groups. Conclusions In ACS patients with or without ST-segment elevation, the primary endpoint did not differ with or without post-PCI bivalirudin infusion but a post-PCI full dose was associated with improved outcomes when compared with no or low-dose post-PCI infusion or heparin (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX [MATRIX]; NCT01433627).
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Heart Rhythm