Should We Use Aspirin or P2Y12 Inhibitor Monotherapy in Stable Ischemic Heart Disease?

PURPOSE OF REVIEW: To summarize the recent evidence and guideline recommendations on aspirin or P2Y12 inhibitor monotherapy in patients with stable ischemic heart disease and provide insights into future directions on this topic, which involves transition to a personalized assessment of bleeding and thrombotic risks. RECENT FINDINGS: It has been questioned whether the evidence for aspirin as the foundational component of secondary prevention in patients with coronary artery disease aligns with contemporary pharmaco-invasive strategies. The recent HOST-EXAM study randomized patients who had received dual antiplatelet therapy for 6 to 18 months without ischemic or major bleeding events to either clopidogrel or aspirin for a further 24 months, and demonstrated that the patients in the clopidogrel arm had significantly lower rates of both thrombotic and bleeding complications compared to those in the aspirin arm. The patient-level PANTHER meta-analysis showed that in patients with established coronary artery disease, P2Y12 inhibitor monotherapy was associated with lower rates of myocardial infarction, stent thrombosis as well as gastrointestinal bleeding and hemorrhagic stroke compared to aspirin monotherapy, albeit with similar rates of all-cause mortality, cardiovascular mortality and major bleeding. Long-term low-dose aspirin is recommended for secondary prevention in patients with stable ischemic heart disease, with clopidogrel monotherapy being acknowledged as a feasible alternative. Dual antiplatelet therapy for six months after percutaneous coronary intervention remains the standard recommendation for patients with stable ischemic heart disease. However, the duration of dual antiplatelet therapy may be shortened and followed by P2Y12 inhibitor monotherapy or prolonged based on individualized evaluation of the patient's risk profile.

Cardiomyopathies in Pregnancy: Trends and Clinical Outcomes in Delivery Hospitalizations in the United States (2005-2020).

BACKGROUND: Cardiomyopathy (CDM) in pregnancy is associated with maternal morbidity and mortality. OBJECTIVES: To explore trends and clinical outcomes in CDM subtypes during delivery hospitalizations. METHODS: We used the National Inpatient Sample database to identify delivery hospitalizations between 2005-2020 by CDM subtypes: peripartum (PPCM), dilated (DCM), hypertrophic (HCM), and restrictive (RCM). Maternal and fetal outcomes were identified using International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes. Baseline characteristics and temporal trends of CDM subtypes were analyzed. Maternal cardiovascular, pregnancy, and fetal outcomes were evaluated by CDM subtype using univariate logistic regression. The primary outcome was in-hospital mortality. RESULTS: During 2005-2020, 37,125 out of 61,811,842 delivery hospitalizations were complicated by CDM. Among CDM-related delivery hospitalizations, the most prevalent were DCM (46%), followed by PPCM (45.6%), HCM (4.6%), and RCM (3.9%). The rates of in-hospital mortality (1.7%), adverse cardiovascular events such as acute heart failure (17%), cardiogenic shock (3.4%), and cardiac arrest (3.1%), and adverse pregnancy outcomes such as preeclampsia (14.2%) and preterm labor (11%), were highest among PPCM (all p < 0.0001). The prevalence of PPCM (49.1% to 38.5%) decreased while the prevalence of HCM (2.7% to 8.8%) and DCM (48% to 52.2%) increased over time. CONCLUSIONS: Over a 15-year period, PPCM had higher rates of in-hospital mortality, cardiovascular events, and adverse pregnancy outcomes compared to other CDM subtypes. While the prevalence of PPCM decreased over time, the prevalence of HCM and DCM increased. Hence, further research on cardiomyopathies during pregnancy and prospective studies on this vulnerable patient cohort are urgently needed.

Catheter Ablation for Channelopathies: When Is Less More?

Ventricular fibrillation (VF) is a common cause of sudden cardiac death in patients with channelopathies, particularly in the young population. Although pharmacological treatment, cardiac sympathectomy, and implantable cardioverter defibrillators (ICD) have been the mainstay in the management of VF in patients with channelopathies, they are associated with significant adverse effects and complications, leading to poor quality of life. Given these drawbacks, catheter ablation has been proposed as a therapeutic option for patients with channelopathies. Advances in imaging techniques and modern mapping technologies have enabled increased precision in identifying arrhythmia triggers and substrate modification. This has aided our understanding of the underlying pathophysiology of ventricular arrhythmias in channelopathies, highlighting the roles of the Purkinje network and the epicardial right ventricular outflow tract in arrhythmogenesis. This review explores the role of catheter ablation in managing the most common channelopathies (Brugada syndrome, congenital long QT syndrome, short QT syndrome, and catecholaminergic polymorphic ventricular tachycardia). While the initial results for ablation in Brugada syndrome are promising, the long-term efficacy and durability of ablation in different channelopathies require further investigation. Given the genetic and phenotypic heterogeneity of channelopathies, future studies are needed to show whether catheter ablation in patients with channelopathies is associated with a reduction in VF, and psychological distress stemming from recurrent ICD shocks, particularly relative to other available therapeutic options (e.g., quinidine in high-risk Brugada patients).

The Wallet Biopsy: Medical Crowdfunding for Heart Transplantation.

Financial considerations continue to impact access to heart transplantation. Transplant recipients face various costs, including, but not limited to, the index hospitalization, immunosuppressive medications, and lodging and travel to appointments. In this study, we sought to describe the state of crowdfunding for individuals being evaluated for heart transplantation. Using the search term heart transplant, 1000 GoFundMe campaigns were reviewed. After exclusions, 634 (63.4%) campaigns were included. Most campaigns were in support of white individuals (57.8%), males (63.1%) and adults (76.7%). Approximately 15% of campaigns had not raised any funds. The remaining campaigns fundraised a median of $53.24 dollars per day. Of the patients, 44% were admitted at the time of the fundraising. Within the campaigns in the United States, the greatest proportions were in the Southeast United States in non-Medicaid expansion states. These findings highlight the significant financial toxicities associated with heart transplantation and the need for advocacy at the governmental and payer levels to improve equitable access and coverage for all.

Addressing Social Determinants of Health in Maternal Cardiovascular Health.

Cardiovascular diseases (CVDs) remain the number-one cause of maternal mortality, with over two-thirds of cases being preventable. Social determinants of health (SDoH) encompass the nonmedical social and environmental factors that an individual experiences that have a significant impact on their health. These stressors disproportionately affect socially disadvantaged and minority populations. Pregnancy is a physiologically stressful state that can unmask underlying CVD risk factors and lead to adverse pregnancy outcomes (APOs). Disparities in APOs are particularly pronounced among individuals of color and those from economically disadvantaged backgrounds. This variation underscores healthcare inequity and access, a failure of the healthcare system. Besides short-term negative effects, APOs also are associated strongly with long-term CVDs. APOs therefore must be identified as a cue for early intervention, for the prevention and management of CVD risk factors. This review explores the intricate relationship among maternal morbidity and mortality, SDoH, and cardiovascular health, and the implementation of health policy efforts to reduce the negative impact of SDoH in this patient population. The review emphasizes the importance of comprehensive strategies to improve maternal health outcomes.

The impact of hospitalization on mortality in patients with connective tissue disease-associated interstitial lung disease: a medical records review study.

BACKGROUND: Interstitial lung disease (ILD) remains one of the most important causes of morbidity and mortality in patients with Connective Tissue Diseases (CTD). This study evaluated the impact of hospitalization on mortality in an ethnically and racially diverse cohort of CTD-ILD patients. METHODS: We conducted a medical records review study at Montefiore Medical Center, Bronx, NY. We included 96 patients and collected data on demographic characteristics, reasons for hospitalization, length of stay, immunosuppressant therapy use, and mortality. We stratified our patients into two cohorts: hospitalized and non-hospitalized. The hospitalized cohort was further subdivided into cardiopulmonary and non-cardiopulmonary admissions. Two-sample tests or Wilcoxon's rank sum tests for continuous variables and Chi-square or Fisher's exact tests for categorical variables were used for analyses as deemed appropriate. RESULTS: We identified 213 patients with CTD-ILD. Out of them, 96 patients met the study's inclusion criteria. The majority of patients were females (79%), and self-identified as Hispanic (54%) and Black (40%). The most common CTDs were rheumatoid arthritis (RA) (29%), inflammatory myositis (22%), and systemic sclerosis (15%). The majority (76%) of patients required at least one hospitalization. In the non-hospitalized group, no deaths were observed, however we noted significant increase of mortality risk in hospitalized group (p = 0.02). We also observed that prolonged hospital stay (> 7 days) as well as older age and male sex were associated with increased mortality. CONCLUSIONS: Prolonged (> 7 days) hospital stay and hospitalization for cardiopulmonary causes, as well as older age and male sex were associated with an increased mortality risk in our cohort of CTD-ILD patients.

The impact of hospitalization on mortality in patients with connective tissue disease-associated interstitial lung disease: a medical records review study

Abstract Background Interstitial lung disease (ILD) remains one of the most important causes of morbidity and mortality in patients with Connective Tissue Diseases (CTD). This study evaluated the impact of hospitalization on mortality in an ethnically and racially diverse cohort of CTD-ILD patients. Methods We conducted a medical records review study at Montefiore Medical Center, Bronx, NY. We included 96 patients and collected data on demographic characteristics, reasons for hospitalization, length of stay, immunosuppressant therapy use, and mortality. We stratified our patients into two cohorts: hospitalized and nonhospitalized. The hospitalized cohort was further subdivided into cardiopulmonary and non-cardiopulmonary admissions. Two-sample tests or Wilcoxon's rank sum tests for continuous variables and Chi-square or Fisher's exact tests for categorical variables were used for analyses as deemed appropriate. Results We identified 213 patients with CTD-ILD. Out of them, 96 patients met the study's inclusion criteria. The majority of patients were females (79%), and self-identified as Hispanic (54%) and Black (40%). The most common CTDs were rheumatoid arthritis (RA) (29%), inflammatory myositis (22%), and systemic sclerosis (15%). The majority (76%) of patients required at least one hospitalization. In the non-hospitalized group, no deaths were observed, however we noted significant increase of mortality risk in hospitalized group (p = 0.02). We also observed that prolonged hospital stay (> 7 days) as well as older age and male sex were associated with increased mortality. Conclusion Prolonged (> 7 days) hospital stay and hospitalization for cardiopulmonary causes, as well as older age and male sex were associated with an increased mortality risk in our cohort of CTD-ILD patients.

Incidence and Prognostic Implications of Cardiac-Implantable Device-Associated Tricuspid Regurgitation: A Meta-Analysis and Meta-Regression Analysis.

New-onset or worsening tricuspid regurgitation (TR) is a well-established complication encountered after cardiac implantable electronic devices (CIEDs). However, there are limited and conflicting data on the true incidence and prognostic implications of this complication. This study aimed to bridge this current gap in the literature. Electronic databases MEDLINE, Embase, and Web of Science were systematically searched from inception to March 2023, for studies reporting the incidence and/or prognosis of CIED-associated new or worsening TR. Potentially eligible studies were screened and selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A random effect model meta-analysis and meta-regression analysis were performed, and I-squared statistic was used to assess heterogeneity. A total of 52 eligible studies, with 130,759 patients were included in the final quantitative analysis with a mean follow-up period of 25.5 months. The mean age across included studies was 69.35 years, and women constituted 46.6% of the study population. The mean left ventricular ejection fraction was 50.15%. The incidence of CIED-associated TR was 24% (95% confidence interval [CI] 20% to 28%, p <0.001) with an odds ratio of 2.44 (95% CI 1.58 to 3.77, p <0.001). CIED-associated TR was independently associated with an increased risk of all-cause mortality (adjusted hazard ratio [aHR] 1.52, 95% CI 1.36 to 1.69, p <0.001), heart failure (HF) hospitalizations (aHR 1.82, 95% CI 1.19 to 2.78, p = 0.006), and the composite of mortality and HF hospitalizations (aHR 1.96, 95% CI 1.33 to 2.87, p = 0.001) in the follow-up period. In conclusion, CIED-associated TR occurred in nearly one-fourth of patients after device implantation and was associated with an increased risk of all-cause mortality and HF hospitalizations.

Significance of Kidney Disease in Cardiovascular Disease Patients.

Cardiorenal syndrome is a condition where is a bidirectional and mutually detrimental relationship between the heart and kidneys. The mechanisms underlying cardiorenal syndrome are multifactorial and complex. Patients with kidney disease exhibit increased cardiovascular risk, presenting as coronary and peripheral artery disease, structural heart disease, arrhythmias, heart failure, and sudden cardiac death, largely occurring because of a systemic proinflammatory state, causing myocardial and vascular remodeling, manifesting as atherosclerotic lesions, vascular and valvular calcification, and myocardial fibrosis, particularly among those with advanced disease. This review summarizes the current understanding and clinical implications of kidney disease in patients with cardiovascular disease.

Antiplatelet therapy for coronary artery disease in 2023: current status and future prospects.

INTRODUCTION: Antiplatelet therapy is the cornerstone for prevention and management of ischemic complications among patients with coronary artery disease. Over the past decades, advancement in stent technologies and increasing awareness about the prognostic impact of major bleeding have led to evolving priorities in the management of antithrombotic regimens, from exclusive concerns regarding recurrent ischemic events to an individualized equipoise between ischemic and bleeding risk through a patient-centered comprehensive approach. AREAS COVERED: The purpose of this review is to highlight the current evidence that supports the various management strategies for antiplatelet therapy and discuss future directions of pharmacological regimens for coronary syndromes. We will also discuss the rationale behind use of antiplatelet therapy, current guideline recommendations, risk scores for ischemic and bleeding risk evaluation, and tools to help assess treatment response. EXPERT OPINION: While tremendous advancements have been made in antithrombotic agents and regimens, future directions for antiplatelet therapy in patients with coronary artery disease would involve focus on novel therapeutic targets, development of new antiplatelet agents, implementation of more innovative regimens with current agents and further research to validate contemporary antiplatelet strategies.

Impact of COVID-19 Infection on the Clinical Outcomes of Pulmonary Embolism Hospitalizations : A Nationwide Analysis.

There is an increased risk of venous thromboembolism among patients with COVID-19 infection, with the risk being higher among those needing the intensive level of care. Existing data is, however, limited regarding the outcomes of patients admitted with concurrent COVID-19 infection and pulmonary embolism (PE). All acute PE admissions were identified from the National Inpatient Sample database during 2020 using ICD-10 codes. Patients were subsequently classified into those with and without COVID-19 infection. The primary outcome of interest was in-hospital mortality. Using multivariate logistic regression, the predictors of mortality were assessed for patients with concurrent acute PE and COVID-19. The database query generated 278,840 adult patients with a primary diagnosis of PE. Of these, 4580 patients had concurrent PE and COVID-19 infection. The concurrent PE and COVID-19 infection group had a higher proportion of Black-American and Hispanic patients, and those living in the zip codes associated with the lowest annualized income compared to the PE alone group. Furthermore, patients in the concurrent PE and COVID-19 infection group had an increased risk of in-hospital mortality (adjusted odds ratio [aOR]:1.62; 95% CI: 1.17-2.24; P = 0.004), septic shock (aOR: 1.66; 95% CI 1.10-2.52; P = 0.016), respiratory failure (aOR: 1.78; 95% CI 1.53-2.06; P = 0.001), and a longer hospital stay [5.5 days vs 4.59 days; P = 0.001). Concurrent COVID-19 and PE admissions is associated with an increased in-hospital mortality, risk of septic shock and respiratory failure, and a longer length of hospital stay.

Frailty assessment: An emerging concept in aged People Living with HIV (PLHIV).

Introduction: As the life expectancy of People Living with HIV (PLHIV) has improved with effective antiretroviral treatment (ART), they now face the challenges of accelerated ageing. Frailty is an emerging concept in the management of PLHIV and up to 28% of PLHIV are identified as frail. Frailty is a determinant of adverse clinical outcomes and is a complex clinical endpoint that has not been studied in India. This exploratory study was done to evaluate frailty and its determinants among PLHIV in India. Materials and Methods: This was a cross-sectional study in 76 PLHIV aged 50 years or more. All the study subjects underwent a comprehensive clinical assessment. The Fried's criteria and Veterans Aging Cohort Study (VACS) Index were used to evaluate for frailty. Socio-demographic, clinical, immunological, and virological variables were assessed for their association with frailty. The study was registered under Clinical Trials Registry-India (ICMR-NIMS): REF/2019/05/025616. Results: The mean age of the subjects was 56.05 ± 5.8 years (range 50-76), and males constituted 81.57% (62/76) of the subjects and majority (60.53%) were underweight. On frailty assessment, 57.89% of the PLHIV were identified as prefrail/frail. Frailty had a significant association with low CD4 count (P = 0.0001) and number of comorbidities (P = 0.017) especially when comorbidities ≥2 (P = 0.04) and polypharmacy (P = 0.033). VACS index, polypharmacy, and low CD4 count ≤200 cells/mm3 were strong predictors of frailty. On multivariate regression analysis, CD4 count ≤200 emerged as the strongest independent predictor of frailty. Conclusion: The study highlighted the high prevalence of frailty and under nutrition among aged PLHIV. The study emphasizes the need for a shift away from traditional clinical endpoints to other outcome measures for a holistic approach to PLHIV.