NEWS & VIEWS type of prosthesis. No important differences exist between the AHA/ACC and the ESC/ EACTS guidehnes as to the choice of the type of prosthesis and the target international normalized ratio for patients with a mechanical prosthesis, which have not changed since 2008. However, a discrepancy remains in the indication for low-dose aspirin, which is a class I recommendation in the AHA/ACC guidelines for all patients with a mechanical prosthesis.' In the 2012 ESC/EACTS guidelines, aspirin has a class lia recommendation in selected patients with associated atherosclerosis or recurrent embolie events."* In the largest randomized trial, the reduction of embolie events in patients treated with aspirin was mainly observed in the rate of heart failure, myocardial infarction, or sudden death, which corresponds broadly to atherosclerosis-associated compücations."" No convincing evidence shows that the addition of aspirin provides any benefit in patients at low thromboembolic risk or without atherosclerosis, which would not be offset by the concomitant increase in major bleeding.' The most-important reason for the 2008 update of the 2006 AHA/ACC guidelines was the change in recommendations for antibiotic prophylaxis of infective endocarditis. This change was a major breakthrough. No update to these recommendations has occurred in the 2014 guidelines, but the limitation of indications for antibioprophylaxis to dental care in high-risk patients is now concordant with the AHA/ACC and ESC guidelines." Importantly, surveys from France, the UK, and the USA validate this strategy, showing that restricting indications for antibioprophylaxis was not associated with an increase in the incidence of endocarditis owing to oral streptococci.' In conclusion, the new AHA/ACC guidelines provide an up-to-date, comprehensive set of recommendations on the contemporary management of valvular heart disease (Box 1).' The vast majority of recommendations are concordant with the ESC/EACTS guidelines.* We hope that this agreement will enhance their effective application, which is still suboptimal in clinical practice. '" The rare discrepancies and the number of level C recommendations highlight the need for further studies to strengthen the level of evidence of subsequent guidelines. Beyond the management of specific valve diseases, the new sections of the AHA/ACC guidelines on risk assessment and shared-decision making emphasize the need for an individualized approach that takes into account a patient's characteristics, wishes, and expectations.

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Cardiology Department, Bichat Hospital, AP-HP, 46 Rue Henri Huchard, 75018 Paris, France (B.I.,A.V.). Correspondence to: B.I. [email protected] Competing interests

B.I. declares that he has received consultant fees from Abbott, Boehringer Ingelheim, and Valtech; and speaker's fees from Edwards Lifesciences. A.V. declares that he is a member of the Advisory Board for Abbott and Valtech, and has received speaker's fees from Edwards Lifesciences and Siemens. 1.

2.

3.

4.

Nishimura, R. A. etal. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation http:// dx.doi.org/10.1161/CIR.0000000000000031. lung, B. & Vahanian, A. Epidemiology of valvular heart disease in the adult. Nat. Rev. Cardiol. 8, 162-172 (2011). Rosenhek, R. et a/. ESC Working Group on Valvular Heart Disease position paper: assessing the risk of Interventions in patients with valvular heart disease. Eur. Heart J. 33, 822-828 (2012). Vahanian, A. et ai. Guidelines on the management of valvular heart disease (version 2012):

the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur. Heart J. 33, 2451-2496 (2012). 5. Lancellotti, P. etal. ESC Working Group on Vaivuiar Heart Disease position paper—heart vaive clinics: organization, structure, and experiences. Eur. Heart J. 34,1597-1606 (2013). 6. Turpie, A. G. et al. A comparison of aspirin with placebo in patients treated with warfarin after heart-vaive replacement. N. Engl.J. Meó. 329, 524-529 (1993). 7. Massel, D. & Little, S. H. Risks and benefits of adding anti-platelet therapy to warfarin among patients with prosthetic heart valves: a metaanalysis. J.Am. Coil. Cardiol. 37,569-578 (2001). 8. Habib, G. et ai. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Eur. Heart J. 30,2369-2413 (2009). 9. Duval, X. Simplification of the prophylaxis of endocarditis: we were right! Arch. Cardiovasc. Dis. 106, 69-71 (2013). 10. lung, B. et al. A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease. Eur. Heart J. 24,1231-1243 (2003).

INTERVENTIONAL CARDIOLOGY

Outcomes in coronary stent trials — 1 year is not enough Vasileios F. Panoulas and Antonio Colombo

The medical literature contains a huge nunnber of studies on the safety and performance of novei stent platforms, with primary outcomes usuaiiy assessed at 6 months or 1 year. The 5-year anaiysis from SORT OUT III demonstrates that, when assessing clinical outcomes in stent triais, 1-year foilow-up is not enough. Panoulas, V F. & Colombo, A. Nat. Rev. Cardiol. 11,318-320 (2014); published online 6 May 2014; doi:10.1038/nrcardio.2014.63

The study by Maeng et al. published online in The Lancet in March 2014, presents the 5-year outcomes of the SORT OUT III study,' a multicentre, open-label, superiority trial of 2,332 patients with an indication for drug-eluting stent (DES) implantation. The investigators found that the superiority of the first-generation sirolimus-eluting Cypher® (C-SES) Select Plus stent (Cordis Corporation, USA) over the zotarolimuseluting Endeavor® (E-ZES) Sprint stent (Medronic Vascular, Inc., USA) that had been evident at the 1-year follow-up had been lost at 5 years. At 1 year, the incidence of the primary outcome of major adverse cardiovascular events (MACE; cardiac death, myocardial infarction [MI],

or target-vessel revascularization) was lower in the C-SES group (C-SES: 3.9% versus E-ZES; 8.0%; P80% of total TLRs in the ENDEAVOR III study^'^ were observed in the first year, results that are confirmed by pooled analyses from the ENDEAVOR programme (n = 3,616). The PROTECT trial," a large, openlabel, multicentre, randomized, superiority trial of 8,791 patients (E-ZES: 4,357 and C-SES: 4,352) from 36 countries, was powered to detect differences in the rates of definite or probable stent thrombosis over time. Although no significant differences in this outcome were found between the two groups at 3 years (E-ZES: 1.4% versus C-SES: 1.8%; P=0-22), the incidence of definite stent thrombosis alone was increased in the C-SES group (C-SES: 1.2% versus E-ZES: 0.7%; P = 0.03)." In addition, time analysis suggested that more definite or probable late stent thromboses (31 days to 1 year) occurred in the E-ZES group (E-ZES: 0.4% versus C-SES: 0.1%; P = 0.017) and more very-late stent thromboses (>1 year) occurred in the C-SES group (C-SES: 1.1% versus E-ZES: 0.3%; P