...it hardly stops there, and considering the more than 40 JACC family publications with a focus on mitral valve dysfunction in 2018 alone, our simple categorization proves to be only a start. ...Because mitral valve regurgitation is the most common valve disorder, many patients have trivial or mild MR, and fortunately, it can remain relatively benign for years to decades. (6) recently applied the definitions of severe MR from the American College of Cardiology/American Heart Association guidelines (effective regurgitant orifice area ≥40 mm2 or regurgitant volume ≥60 ml/beat) to those of the European Society of Cardiology/European Association for Cardiothoracic Surgery guidelines (effective regurgitant orifice area ≥20 mm2 or regurgitant volume ≥30 ml/beat) among several hundred patients with heart failure, reduced ejection fraction, and secondary/functional MR. While both guidelines reasonably predicted long-term mortality, the American College of Cardiology/American Heart Association guidelines appeared to better predict outcome (mortality) in contemporary practice (6). The latter observation may be of particular importance in view of the differences in echocardiographic inclusion criteria and clinical outcomes among patients enrolled into the MITRA-FR (Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation) and COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trials investigating the impact of percutaneous edge-to-edge repair in patients with secondary MR (7–9). Because the natural history of untreated severe primary and secondary MR is poor, it is important not only to recognize patients with MR prior to their disease becoming severe, but also to intervene at an appropriate time. Patients who have developed symptoms, who have a decline in functional status, or who have evidence for ventricular function impairment or new-onset atrial fibrillation have a worse prognosis. ...it is crucial to identify such patients prior to the development of attributable symptoms or ventricular dysfunction.
The aim of this study was to assess the impact of age on the safety and efficacy of ticagrelor monotherapy after percutaneous coronary intervention (PCI).
As the risk for bleeding and ischemic ...complications after PCI increases with age, the authors conducted a pre-specified analysis of the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial to evaluate the possible benefits of ticagrelor monotherapy according to age.
The TWILIGHT trial enrolled patients undergoing PCI with drug-eluting stents who fulfilled at least 1 clinical and 1 angiographic high-risk criterion. Age ≥65 years was a clinical entry criterion. After 3 months of dual-antiplatelet therapy with ticagrelor, event-free patients were randomized to ticagrelor plus placebo or ticagrelor plus aspirin for an additional 12 months. The primary endpoint was Bleeding Academic Research Consortium type 2, 3, or 5 bleeding. The key secondary endpoint was the composite of all-cause death, myocardial infarction, or stroke.
A total of 3,113 patients (47.7%) were ≥65 years of age. At 1 year after randomization, ticagrelor monotherapy significantly reduced BARC type 2, 3, or 5 bleeding (4.5% vs. 8.2%; hazard ratio: 0.53; 95% confidence interval: 0.40 to 0.71) without increasing ischemic events (4.2% vs. 4.4%; hazard ratio: 0.96; 95% confidence interval: 0.68 to 1.35) compared with ticagrelor plus aspirin among patients ≥65 years of age. These findings were consistent in patients <65 years of age with respect to the primary (p
= 0.62) and key secondary (p
= 0.77) endpoints and across different age categories.
A strategy of ticagrelor monotherapy following 3 months of dual-antiplatelet therapy significantly reduced clinically relevant bleeding compared with ticagrelor plus aspirin without an increase in ischemic events, irrespective of age.
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