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New England Journal of Medicine

Stalled Federal Efforts to End Surprise Billing — The Role of Private Equity
New England Journal of Medicine, Volume 382, Issue 13, Page 1189-1191, March 2020.
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Misguided Changes to SNAP — Defending a Public Health Intervention for the Poor
New England Journal of Medicine, Volume 382, Issue 13, Page 1191-1193, March 2020.
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Defining the Epidemiology of Covid-19 — Studies Needed
New England Journal of Medicine, Volume 382, Issue 13, Page 1194-1196, March 2020.
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Suicide — Rewriting My Story
New England Journal of Medicine, Volume 382, Issue 13, Page 1196-1197, March 2020.
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Heartbeat: risk of stroke in patients with heart failure
In patients with heart failure (HF), the increased risk of ischaemic stroke often is attributed to coexisting atrial fibrillation (AF). To test the hypothesis that there is a higher risk of ischaemic stroke in patients with HF, even in the absence of AF, Chou and colleagues1 used data from the Taiwan National Health Insurance programme. Over 12 000 patients with newly diagnosed HF were matched by propensity score to the same number of patients without HF, after excluding patients with AF or atrial flutter at baseline or during the follow-up period, as well as patients with previous stroke or acute myocardial infarction. The risk of stroke over a mean follow-up of about 6 years in those with HF was higher than in those without HF (subdistribution HR (SHR)=1.51, 95% CI: 1.37 to 1.66). There also was a higher cumulative risk of stroke and acute myocardial infarction in those with...
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Fabry cardiomyopathy: missing links from genotype to phenotype
The hunt for a genetic cause Fabry disease is an X linked metabolic disorder due to a lack of the lysosomal enzyme alpha galactosidase A. Over 900 variants in the GLA gene are reported, the majority being private mutations restricted to individual families. Classic Fabry disease is the severe form of the condition. It is rare (incidence less than 1:100 000), arising from gene mutations that lead to zero enzymatic activity and has widespread systemic manifestations. By contrast, late-onset Fabry disease is much commoner and is characterised by missense mutations which are typically associated with up to 30% residual enzyme activity in males and often only affects a single organ system. Newborn screening programmes have revealed a high incidence of variants in GLA. Cardiomyopathy in adults is frequently the cardinal feature but associating this with particular genetic variants is confounded by criteria that ascribe their clinical consequence as...
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JACC Instructions for Authors
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2-Year Outcomes After Stenting of Lipid-Rich and Nonrich Coronary Plaques
AbstractBackground Autopsy studies suggest that implanting stents in lipid-rich plaque (LRP) may be associated with adverse outcomes. Objectives The purpose of this study was to evaluate the association between LRP detected by near-infrared spectroscopy (NIRS) and clinical outcomes in patients with coronary artery disease treated with contemporary drug-eluting stents. Methods In this prospective, multicenter registry, NIRS was performed in patients undergoing coronary angiography and possible percutaneous coronary intervention (PCI). Lipid core burden index (LCBI) was calculated as the fraction of pixels with the probability of LRP >0.6 within a region of interest. MaxLCBI4mm was defined as the maximum LCBI within any 4-mm-long segment. Major adverse cardiac events (MACE) included cardiac death, myocardial infarction, definite or probable stent thrombosis, or unplanned revascularization or rehospitalization for progressive angina or unstable angina. Events were subcategorized as culprit (treated) lesion–related, nonculprit (untreated) lesion–related, or indeterminate. Results Among 1,999 patients who were enrolled in the COLOR (Chemometric Observations of Lipid Core Plaques of Interest in Native Coronary Arteries Registry), PCI was performed in 1,621 patients and MACE occurred in 18.0% of patients, of which 8.3% were culprit lesion–related, 10.7% were nonculprit lesion–related, and 3.1% were indeterminate during 2-year follow-up. Complications from NIRS imaging occurred in 9 patients (0.45%), which resulted in 1 peri-procedural myocardial infarction and 1 emergent coronary bypass. Pre-PCI NIRS imaging was obtained in 1,189 patients, and the 2-year rate of culprit lesion–related MACE was not significantly associated with maxLCBI4mm (hazard ratio of maxLCBI4mm per 100: 1.06; 95% confidence interval: 0.96 to 1.17; p = 0.28) after adjusting clinical and procedural factors. Conclusions Following PCI with contemporary drug-eluting stents, stent implantation in NIRS-defined LRPs was not associated with increased periprocedural or late adverse outcomes compared with those without significant lipid.
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Vulnerable Plaque and Einsteins Definition of Insanity
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Intravenous Statin Administration During Myocardial Infarction Compared With Oral Post-Infarct Administration
AbstractBackground Beyond lipid-lowering, statins exert cardioprotective effects. High-dose statin treatment seems to reduce cardiovascular complications in high-risk patients. The ideal timing and administration regime remain unknown. Objectives This study compared the cardioprotective effects of intravenous statin administration during myocardial infarction (MI) with oral administration immediately post-MI. Methods Hypercholesterolemic pigs underwent MI induction (90 min of ischemia) and were kept for 42 days. Animals were distributed in 3 arms (A): A1 received an intravenous bolus of atorvastatin during MI; A2 received an intravenous bolus of vehicle during MI; and A3 received oral atorvastatin within 2 h post-MI. A1 and A3 remained on daily oral atorvastatin for the following 42 days. Cardiac magnetic resonance analysis (days 3 and 42 post-MI) and molecular/histological studies were performed. Results At day 3, A1 showed a 10% reduction in infarct size compared with A3 and A2 and a 50% increase in myocardial salvage. At day 42, both A1 and A3 showed a significant decrease in scar size versus A2; however, A1 showed a further 24% reduction versus A3. Functional analyses revealed improved systolic performance in A1 compared with A2 and less wall motion abnormalities in the jeopardized myocardium versus both groups at day 42. A1 showed enhanced collagen content and AMP-activated protein kinase activation in the scar, increased vessel density in the penumbra, higher tumor necrosis factor α plasma levels and lower peripheral blood mononuclear cell activation versus both groups. Conclusions Intravenous administration of atorvastatin during MI limits cardiac damage, improves cardiac function, and mitigates remodeling to a larger extent than when administered orally shortly after reperfusion. This therapeutic approach deserves to be investigated in ST-segment elevation MI patients.
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Heart Rhythm