CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 58 AFRICA References 1. Wu Y, Jiang W, Li D, Lei Chen, Ye W, Renet C, et al. Surgery of ascending aorta with complex procedures for aortic dissection through upper mini-sternotomy versus conventional sternotomy. J Cardiothorac Surg 2020; 15: 57. 2. Toprak B, Szöcs K, Zengin-Sahm E, et al. Marfan syndrome versus bicuspid aortic valve disease: comparative analysis of obstetric outcome and pregnancy-associated immediate and long-term aortic complications. J Clin Med 2020; 9(4): 1124. 3. Goyal A, Chhabra L, Parekh A, Bhyan P, Khalid N. Minimally invasive aortic valve surgery. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2020. 4. Johnson CA Jr, Wood KL, Melvin AL, Lebow BF, Knight PA. Video assisted right mini-thoracotomy for aortic root replacement. J Vis Surg 2018; 4:38. 5. Nisanoglu V, Battaloglu B, Erdil N, Ozgur B, Kuzucu A. Surgical approach for Stanford type A aortic dissection in a patient with Marfan syndrome and pectus excavatum. Tex Heart Inst J 2007; 34(2): 240–243. 6. Media A, Pilegaard H, de Paoli F. Combining correction of pectus excavatum and open-heart surgery in a single-stage procedure. Ann Thorac Surg 2020; 109(1): e71–e74. 7. Corvera J, Fehrenbacher J. Total arch and descending thoracic aortic replacement by left thoracotomy. Ann Thorac Surg 2012; 93(5): 1510– 1515; discussion 1515–1516. 8. Thors A, Haurani M, Nelson K, Crestanello J. Aortic arch replacement through a left thoracotomy for right-sided aortic arch aneurysm with complete vascular ring. Ann Thorac Surg 2014; 97(1): 317–319. continued from page 39 In the highest LPA-GRS quintile, aspirin reduced major adverse cardiovascular events by 3.3 events per 1 000 personyears (approximately two-fold higher magnitude of risk reduction compared with the overall cohort), with an increase in bleeding risk of 1.6 events per 1 000 person-years (almost identical bleeding risk to the overall cohort). This shifted the benefit-versus-harm balance in the highest LPA-GRS quintile to a net benefit of 1.7 events per 1 000 person-years. Similar findings in Women’s Health Study Lacaze and colleagues said similar results had also been seen in another large aspirin primary-prevention study, the Women’s Health Study (WHS), which compared aspirin 100 mg every other day with placebo in initially healthy younger women. Previously reported results showed that women carrying the rs3798220-C variant, associated with highly elevated Lp(a) levels, had a two-fold higher risk of cardiovascular events than non-carrier women in the placebo group, but this risk was reduced in the aspirin group. And there was no increased risk of bleeding in women with elevated Lp(a) levels. ‘These results, in the absence of any other randomised, controlled trial evidence or approved therapy for treating Lp(a)-associated risk, have been used by some physicians as justification for prescribing aspirin in patients with elevated Lp(a),’ Lacaze and colleagues noted. ‘In the present study of the ASPREE trial population, our results were consistent with the WHS analysis, despite randomising older individuals (both men and women),’ they said They say this validation of the WHS result provides evidence that a very high-risk subgroup of individuals with highly elevated Lp(a) – those carrying the rs3798220-C allele – may benefit from low-dose aspirin for the primary prevention of cardiovascular events. Furthermore, the benefits in this subgroup specifically may outweigh any bleeding risk. But they point out that rs3798220-C carriers comprise only a small portion of all individuals with elevated Lp(a) levels in the general population, while the polygenic LPA-GRS explains about 60% of the variation in directly measured plasma Lp(a) levels and has the potential advantage of being able to identify a larger group of individuals at increased risk. The researchers noted, however, that it is not clear to what extent the LPA-GRS results add further evidence to suggest that individuals with elevated Lp(a) levels, beyond rs3798220-C carriers, may be more likely to benefit from aspirin. ‘If the benefit of aspirin extends beyond very high-risk rs3798220-C carriers alone, to the broader 20 to 30% of individuals with elevated Lp(a) levels, the potential utility of aspirin for the primary prevention of cardiovascular events would increase substantially,’ they say. ‘Very high clinical relevance’ In an accompanying editorial, Dr Ana Devesa, Dr Borja Ibanez, PhD, and Dr Valentin Fuster, PhD, from The National Center for Cardiovascular Research, Madrid, Spain, said that: ‘Lacaze et al. are to be congratulated for a study of very high clinical relevance that represents a first indication for primary prevention for patients at high cardiovascular risk.’ They said the pathogenic mechanism of Lp(a) is believed to be a combination of prothrombotic and pro-atherogenic effects, and the current findings support the hypothesis that the prothrombotic mechanism of Lp(a) is mediated by platelet aggregation. This would explain the occurrence of thrombotic events in the presence of atherosclerosis in that elevated Lp(a) levels may induce platelet adhesion and aggregation to the activated atherosclerotic plaque, thus enhancing the atherothrombotic process. Moreover, activated platelets release several mediators that result in cell adhesion and attraction of chemokines and pro-inflammatory cytokines, driving an inflammatory response and mediating atherosclerosis progression, they add. The editorialists highlight the limitations of the study already acknowledged by the authors: the analysis used genotypes rather than elevated Lp(a) levels and included only those of European ancestry, meaning the results are difficult to extrapolate to other populations. ‘The next steps in clinical practice should be defined, and there are still questions to be answered,’ they conclude. ‘Will every patient benefit from antithrombotic therapies? Should all patients who have elevated Lp(a) levels be treated with aspirin?’ Source: MedicalBrief 2022
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