In higher-risk, statin-intolerant adults with diabetes, bempedoic acid reduced MACE at a median 3 y.

SOURCE CITATION: Ray KK, Nicholls SJ, Li N, et al; CLEAR OUTCOMES Committees and Investigators. Efficacy and safety of bempedoic acid among patients with and without diabetes: prespecified analysis of the CLEAR Outcomes randomised trial. Lancet Diabetes Endocrinol. 2024;12:19-28. 38061370.

In statin-intolerant adults with, or at risk for, CV disease, bempedoic acid reduced MACE at a median 41 mo.

SOURCE CITATION: Nissen SE, Lincoff MA, Brennan D, et al; CLEAR Outcomes Investigators. Bempedoic acid and cardiovascular outcomes in statin-intolerant patients. N Engl J Med. 2023;388:1353-1364. 36876740.

Clinical and cost implications of deferred testing in low-risk patients with stable chest pain: a simulation using the PROMISE trial.

Current guidelines recommend a deferred testing approach in low-risk patients presenting with stable chest pain. After simulating a deferred testing approach using the PROMISE Minimal Risk Score to identify 915 minimal risk participants with cost data from the PROMISE trial, a deferred testing strategy was associated with an adjusted cost savings of -$748.74 (95% CI: -1646.97, 158.06) per participant and 74.6% of samples had better clinical outcomes and lower mean cost. This supports the current guideline recommended deferred testing approach in low-risk patients with stable chest pain.

Coordinating Cardiology clinics randomized trial of interventions to improve outcomes (COORDINATE) - Diabetes: rationale and design.

Several medications that are proven to reduce cardiovascular events exist for individuals with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease, however they are substantially underused in clinical practice. Clinician, patient, and system-level barriers all contribute to these gaps in care; yet, there is a paucity of high quality, rigorous studies evaluating the role of interventions to increase utilization. The COORDINATE-Diabetes trial randomized 42 cardiology clinics across the United States to either a multifaceted, site-specific intervention focused on evidence-based care for patients with T2DM or standard of care. The multifaceted intervention comprised the development of an interdisciplinary care pathway for each clinic, audit-and-feedback tools and educational outreach, in addition to patient-facing tools. The primary outcome is the proportion of individuals with T2DM prescribed three key classes of evidence-based medications (high-intensity statin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and either a sodium/glucose cotransporter-2 inhibitor (SGLT-2i) inhibitor or glucagon-like peptide 1 receptor agonist (GLP-1RA) and will be assessed at least 6 months after participant enrollment. COORDINATE-Diabetes aims to identify strategies that improve the implementation and adoption of evidence-based therapies.

In ASCVD, moderate-intensity statin + ezetimibe was noninferior to high-intensity statin alone at 3 y.

SOURCE CITATION: Kim BK, Hong SJ, Lee YJ, et al. Long-term efficacy and safety of moderate-intensity statin with ezetimibe combination therapy versus high-intensity statin monotherapy in patients with atherosclerotic cardiovascular disease (RACING): a randomised, open-label, non-inferiority trial. Lancet. 202;400:380-90. 35863366.

Recommendations for use of ezetimibe and/or PCSK9 inhibitors in patients with elevated LDL-C.

SOURCE CITATION: Hao Q, Aertgeerts B, Guyatt G, et al. PCSK9 inhibitors and ezetimibe for the reduction of cardiovascular events: a clinical practice guideline with risk-stratified recommendations. BMJ. 2022;377:e069066. 35508320.

In CV disease, GLP-1 RAs and SGLT2 inhibitors reduce CV mortality.

SOURCE CITATION: Kanie T, Mizuno A, Takaoka Y, et al. Dipeptidyl peptidase-4 inhibitors, glucagon-like peptide 1 receptor agonists and sodium-glucose co-transporter-2 inhibitors for people with cardiovascular disease: a network meta-analysis. Cochrane Database Syst Rev. 2021;10:CD013650. 34693515.

Should We "RESPECT EPA" More Now? EPA and DHA for Cardiovascular Risk Reduction.

PURPOSE OF REVIEW: There has been much debate surrounding the use of omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), for cardiovascular (CV) risk reduction. RECENT FINDINGS: Recent trials of EPA and DHA have offered conflicting evidence. Some demonstrate reduction in CV risk using EPA alone in select populations. Others have demonstrated no benefit, with potential for side effects, such as new-onset atrial fibrillation. Both EPA and DHA have favorable impact on lipids and inflammation, suggesting some biological plausibility for CV risk reduction. However, clinical trials of these agents have produced mixed results. Based on available evidence, EPA may work better for CV risk than DHA and EPA combined. The benefit of EPA seems to be dose dependent, though higher doses may have more side effects. Further research is needed to define the role of EPA and DHA in the landscape of CV risk reduction.

The prospective randomized trial of the optimal evaluation of cardiac symptoms and revascularization: Rationale and design of the PRECISE trial.

BACKGROUND: Clinicians vary widely in their preferred diagnostic approach to patients with non-acute chest pain. Such variation exposes patients to potentially avoidable risks, as well as inefficient care with increased costs and unresolved patient concerns. METHODS: The Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization (PRECISE) trial (NCT03702244) compares an investigational "precision" diagnostic strategy to a usual care diagnostic strategy in participants with stable chest pain and suspected coronary artery disease (CAD). RESULTS: PRECISE randomized 2103 participants with stable chest pain and a clinical recommendation for testing for suspected CAD at 68 outpatient international sites. The investigational precision evaluation strategy started with a pre-test risk assessment using the PROMISE Minimal Risk Tool. Those at lowest risk were assigned to deferred testing (no immediate testing), and the remainder received coronary computed tomographic angiography (cCTA) with selective fractional flow reserve (FFRCT) for any stenosis meeting a threshold of ≥30% and <90%. For participants randomized to usual care, the clinical care team selected the initial noninvasive or invasive test (diagnostic angiography) according to customary practice. The use of cCTA as the initial diagnostic strategy was proscribed by protocol for the usual care strategy. The primary endpoint is time to a composite of major adverse cardiac events (MACE: all-cause death or non-fatal myocardial infarction) or invasive cardiac catheterization without obstructive CAD at 1 year. Secondary endpoints include health care costs and quality of life. CONCLUSIONS: PRECISE will determine whether a precision approach comprising a strategically deployed combination of risk-based deferred testing and cCTA with selective FFRCT improves the clinical outcomes and efficiency of the diagnostic evaluation of stable chest pain over usual care.

LOW-HARM score predicted mortality in patients hospitalized with COVID-19 in Mexico.

SOURCE CITATION: Soto-Mota A, Marfil-Garza BA, Martinez Rodriguez E, et al. The low-harm score for predicting mortality in patients diagnosed with COVID-19: a multicentric validation study. J Am Coll Emerg Physicians Open. 2020;1:1436-43. 33230506.

Eradicating Atherosclerosis: Should We Start Statins at Younger Ages and at Lower LDL-Cs.

PURPOSE OF REVIEW: Given the increasing burden of cardiovascular disease, we review the literature for earlier initiation of statin therapy at younger ages and lower low-density lipoprotein cholesterol (LDL-C) levels, with the goal of preventing the development of atherosclerosis prior to clinical events. RECENT FINDINGS: There is a rising prevalence of dyslipidemia among younger adults. Although guidelines offer recommendations for adults over 40, there is little guidance for the management of younger adults with moderately elevated LDL-C levels. Earlier and more aggressive statin use may slow progression, or even halt atherosclerosis, and may likewise be beneficial and cost-effective on a population level. Further research is needed to define the exact age and LDL-C level at which to start statin therapy. Until then, more detailed risk stratification with lab testing and imaging should be used to identify younger adults at the highest risk.

Lipid-Lowering Therapy in Women of Childbearing Age: a Review and Stepwise Clinical Approach.

PURPOSE OF REVIEW: Women are less often recognized to have cardiovascular disease (CVD) risk and are underrepresented in randomized trials of lipid-lowering therapy. Here, we summarize non-pharmacologic and pharmacologic strategies for lipid-lowering in women of childbearing age, lipid changes during pregnancy and lactation, discuss sex-specific outcomes in currently available literature, and discuss future areas of research. RECENT FINDINGS: While lifestyle interventions form the backbone of CVD prevention, some women of reproductive age have an indication for pharmacologic lipid-lowering. Sex-based evidence is limited but suggests that both statin and non-statin lipid-lowering agents are beneficial regardless of sex, especially at high cardiovascular risk. Pharmacologic lipid-lowering therapies, both during the pregnancy period and during lactation, have historically been and continue to be limited by safety concerns. This oftentimes limits lipid-lowering options in women of childbearing age. In this review, we summarize lipid-lowering strategies in women of childbearing age and the impact of therapies during pregnancy and lactation. The limited sex-specific data regarding efficacy, adverse events, and cardiovascular outcomes underscore the need for a greater representation of women in randomized controlled trials. More data on lipid-lowering teratogenicity are needed, and through increased clinician awareness and reporting to incidental exposure registries, more data can be harvested.

Impact of Culture, Spirituality, and Mental Health Attitudes on Intergenerational Asian-American Caregivers: A Pilot Study.

IMPORTANCE: Asian-Americans are more likely than other ethnic groups to care for older family members and less likely to seek mental health services. The research on caregiver burden among Asian-American intergenerational caregivers is limited. OBJECTIVE: To investigate how spirituality and mental health help-seeking attitudes correlate with and predict perceived feelings of caregiver burden among Asian-American caregivers. Favorable mental health help-seeking attitudes were predicted to negatively correlate with caregiver burden, and spirituality was predicted to negatively correlate with and negatively predict caregiver burden. DESIGN: Quantitative survey research. SETTING: Community mental health. PARTICIPANTS: One hundred one participants were recruited using the following inclusion criteria: Asian-Americans who currently or previously provided care to an Asian family member at least one generation older than the caregiver for at least 1 mo and in the past 3 yr. Outcomes and Measures: Items from the Burden Scale for Family Caregivers, Spirituality Scale, Expressions of Spirituality Inventory-Revised, Mental Help Seeking Attitudes Scale, and Self-Stigma of Seeking Psychological Help measured caregiver burden, spirituality, and mental health help-seeking attitudes. RESULTS: A statistically significant negative correlation was found between caregiver burden and spirituality and between caregiver burden and mental health help-seeking attitudes. Spirituality and number of domains of care were statistically significant predictors of caregiver burden. CONCLUSIONS AND RELEVANCE: Spirituality was found to negatively predict caregiver burden among Asian-American intergenerational caregivers. Mental health help-seeking attitudes were negatively correlated with caregiver burden. Occupational therapy practitioners have the opportunity to integrate spirituality and culturally sensitive mental health promotion into their services to Asian-Americans. What This Article Adds: Evidence that spirituality is a negative predictor of caregiver burden for Asian-American intergenerational caregivers offers a unique opportunity for occupational therapy practitioners to offer alternative methods of mental health promotion with this population. Understanding that spirituality and mental health help-seeking attitudes are culturally mediated allows practitioners to be informed about a dynamic in Asian-American culture.

In older patients with NSTE-ACS, clopidogrel safely reduced bleeding compared with ticagrelor at 1 year.

SOURCE CITATION: Gimbel M, Qaderdan K, Willemsen L, et al. Clopidogrel versus ticagrelor or prasugrel in patients aged 70 years or older with non-ST-elevation acute coronary syndrome (POPular AGE): the randomised, open-label, non-inferiority trial. Lancet. 2020;395:1374-81. 32334703.

In patients at high CV risk receiving simvastatin, the Myopathy Risk Score predicted statin-related myopathy.

SOURCE CITATION: Hopewell JC, Offer A, Haynes R, et al. Independent risk factors for simvastatin-related myopathy and relevance to different types of muscle symptom. Eur Heart J. 2020;41:3336-42. 32702748.

Spontaneous carotid artery dissection: a rare cause of stroke in pregnancy and approach to diagnosis and management.

Acute onset of neurological symptoms in a pregnant female is a rare medical emergency. We report a case of a 38-year-old female who presented with a stroke secondary to carotid artery dissection. Our case illustrates the need to consider vascular imaging before administering thrombolytic therapy in peripartum females to avoid unnecessary risks to either the mother or the fetus. Management is controversial and is discussed briefly.

Diagnosing Coronary Artery Disease in the Patient Presenting with Stable Ischemic Heart Disease: The Role of Anatomic versus Functional Testing.

There are unique advantages and disadvantages to functional versus anatomic testing in the work-up of patients who present with symptoms suggestive of obstructive coronary artery disease. Evaluation of these individuals starts with an assessment of pre-test probability, which guides subsequent testing decisions. The choice between anatomic and functional testing depends on this pre-test probability. In general, anatomic testing has particular utility among younger individuals and women; while functional testing can be helpful to rule-in ischemia and guide revascularization decisions. Ultimately, selection of the most appropriate test should be individualized to the patient and clinical scenario.

Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis.

Background: Patients with type 2 diabetes mellitus (DM) comprise more than a quarter of all patients undergoing percutaneous coronary intervention and are at higher risk of adverse events. We sought to reexamine the optimal duration of dual antiplatelet therapy (DAPT) postpercutaneous coronary intervention in patients with DM. Methods: We systematically included randomized controlled trials comparing any 2 of 1, 3, 6, and 12 months of DAPT that reported major adverse cardiovascular events (MACE), net adverse clinical events (NACE), bleeding, or stent thrombosis in DM, and performed a frequentist network meta-analysis. We also performed a sensitivity analysis of trials that exclusively enrolled patients with acute coronary syndrome. Results: In 16 randomized controlled trials comprising 16,376 adults with DM, there was no significant difference in NACE, MACE, stent thrombosis, or major bleeding between pairwise comparisons of 1, 3, 6, and 12 months of DAPT, except for a signal for lower bleeding with 3 months of DAPT compared to 12 (risk ratio, 0.72; 95% CI, 0.51-0.99). Sensitivity analysis of trials that solely included acute coronary syndrome similarly showed no significant difference in MACE between 1, 3, 6, and 12 months of DAPT. Conclusions: Our study found no meaningful difference in NACE or MACE between pairwise comparisons of 1, 3, 6, and 12 months of DAPT by study-level meta-analysis of patients with DM, with lower bleeding risk observed with 3 months than with 12 months of DAPT. This finding may provide clinicians greater flexibility to personalize patients' DAPT duration based on other non-DM comorbidities that might affect bleeding or thrombosis risk.

Shorter Dual Antiplatelet Therapy for Older Adults After Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis.

Importance: The optimal duration of dual antiplatelet therapy (DAPT) for older adults after percutaneous coronary intervention (PCI) is uncertain because they are simultaneously at higher risk for both ischemic and bleeding events. Objective: To investigate the association of abbreviated DAPT with adverse clinical events among older adults after PCI. Data Sources: The Cochrane Library, Google Scholar, Embase, MEDLINE, PubMed, Scopus, and Web of Science were searched from inception to August 9, 2023. Study Selection: Randomized clinical trials comparing any 2 of 1, 3, 6, and 12 months of DAPT were included if they reported results for adults aged 65 years or older or 75 years or older. Data Extraction and Synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was used to abstract data and assess data quality. Risk ratios for each duration of DAPT were calculated with alternation of the reference group. Main Outcomes and Measures: The primary outcome of interest was net adverse clinical events (NACE). Secondary outcomes were major adverse cardiovascular events (MACE) and bleeding. Results: In 14 randomized clinical trials comprising 19 102 older adults, no differences were observed in the risks of NACE or MACE for 1, 3, 6, and 12 months of DAPT. However, 3 months of DAPT was associated with a lower risk of bleeding compared with 6 months of DAPT (relative risk [RR], 0.50 [95% CI, 0.29-0.84]) and 12 months of DAPT (RR, 0.57 [95% CI, 0.45-0.71]) among older adults. One month of DAPT was also associated with a lower risk of bleeding compared with 6 months of DAPT (RR, 0.68 [95% CI, 0.54-0.86]). Conclusions and Relevance: In this systematic review and meta-analysis of different durations of DAPT for older adults after PCI, an abbreviated DAPT duration was associated with a lower risk of bleeding without any concomitant increase in the risk of MACE or NACE despite the concern for higher-risk coronary anatomy and comorbidities among older adults. This study, which represents the first network meta-analysis of this shortened treatment for older adults, suggests that clinicians may consider abbreviating DAPT for older adults.

Closing the Last Mile Gap in Access to Multimodality Imaging in Rural Settings: Design of the Imaging Core of the Risk Underlying Rural Areas Longitudinal Study.

Achieving optimal cardiovascular health in rural populations can be challenging for several reasons including decreased access to care with limited availability of imaging modalities, specialist physicians, and other important health care team members. Therefore, innovative solutions are needed to optimize health care and address cardiovascular health disparities in rural areas. Mobile examination units can bring imaging technology to underserved or remote communities with limited access to health care services. Mobile examination units can be equipped with a wide array of assessment tools and multiple imaging modalities such as computed tomography scanning and echocardiography. The detailed structural assessment of cardiovascular and lung pathology, as well as the detection of extracardiac pathology afforded by computed tomography imaging combined with the functional and hemodynamic assessments acquired by echocardiography, yield deep phenotyping of heart and lung disease for populations historically underrepresented in epidemiological studies. Moreover, by bringing the mobile examination unit to local communities, innovative approaches are now possible including engagement with local professionals to perform these imaging assessments, thereby augmenting local expertise and experience. However, several challenges exist before mobile examination unit-based examinations can be effectively integrated into the rural health care setting including standardizing acquisition protocols, maintaining consistent image quality, and addressing ethical and privacy considerations. Herein, we discuss the potential importance of cardiac multimodality imaging to improve cardiovascular health in rural regions, outline the emerging experience in this field, highlight important current challenges, and offer solutions based on our experience in the RURAL (Risk Underlying Rural Areas Longitudinal) cohort study.