The Role and Implications of COVID-19 in Incident and Prevalent Heart Failure.

PURPOSE OF REVIEW: This review examines the pathophysiological interactions between COVID-19 and heart failure, highlighting the exacerbation of heart failure in COVID-19 patients. It focuses on the complex mechanisms driving worse outcomes in these patients. RECENT FINDINGS: Patients with pre-existing heart failure experience more severe symptoms and higher mortality rates due to mechanisms such as cytokine storms, myocardial infarction, myocarditis, microvascular dysfunction, thrombosis, and stress cardiomyopathy. Elevated biomarkers like troponin and natriuretic peptides correlate with severe disease. Long-term cardiovascular risks for COVID-19 survivors include increased incidence of heart failure, non-ischemic cardiomyopathy, cardiac arrest, and cardiogenic shock. COVID-19 significantly impacts patients with pre-existing heart failure, leading to severe symptoms and higher mortality. Elevated cardiac biomarkers are indicators of severe disease. Acute and long-term cardiovascular complications are common, calling for ongoing research into targeted therapies and improved management strategies to better prevent, diagnose, and treat heart failure in the context of COVID-19.

Carotid artery stenting versus carotid endarterectomy for symptomatic or asymptomatic extracranial carotid stenosis: A national cohort study.

INTRODUCTION: Stroke is now the 5th leading cause of death in the United States, and carotid artery stenosis is the cause of about 20% to 25% of strokes. We hypothesized that CAS may be an alternative to CEA in both symptomatic and asymptomatic patients with carotid artery stenosis. METHODS: We evaluated the clinical characteristics, adverse events and mortality of patients with carotid artery stenosis comparing CEA vs. CAS using data from a national population-based cohort study from January 1, 2016, to December 30, 2020. RESULTS: We evaluated 374,875 patients with carotid stenosis, of whom 344,020 had asymptomatic carotid stenosis and 30,855 had symptomatic carotid stenosis. CAS was associated with higher mortality in both symptomatic and asymptomatic carotid stenosis, compared to CEA, with the trend slightly decreasing for both interventions from the years 2018-2020. CEA was associated with lower adverse events in both symptomatic and asymptomatic carotid stenosis, compared to CAS. CONCLUSIONS: Our current data suggest a benefit of CEA over CAS for both symptomatic and asymptomatic carotid stenosis with lower complications, lower mortality and a higher rate of discharge. However, this is not a head-to-head comparison as it becomes selection bias for this procedure; therefore, further prospective head-to-head comparison between 2 groups in the same patient population is needed.

Revascularization Options for Left Main Disease: What Clinicians Need to Know.

PURPOSE OF REVIEW: Left main disease represents the highest-risk lesion subset of coronary artery disease and is associated with adverse cardiovascular events. Accordingly, we aim to understand how the significance of left main disease is assessed by different modalities, followed by a review of management options in current era. RECENT FINDINGS: Invasive coronary angiogram remains the gold standard for assessment of left main disease, but intracoronary imaging or physiological testing is indicated for angiographically equivocal disease. Revascularization by either coronary artery bypass surgery or percutaneous coronary intervention is strongly recommended, which have been compared by six randomized trials, as well as recent meta-analyses. Surgical revascularization remains the preferred mode of revascularization, especially in patients with high lesion complexity and left ventricular dysfunction. Randomized studies are needed to understand if current-generation stents with the use of intracoronary imaging and improved medical therapy could match outcomes with surgical revascularization.

Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association.

As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD.

Coronavirus disease-19 and cardiovascular disease: A risk factor or a risk marker?

Severe acute respiratory syndrome coronavirus-2 causes the clinical syndrome of coronavirus disease of 2019 (COVID-19) which has become a global pandemic resulting in significant morbidity and mortality. While the virus primarily affects the respiratory system, it also causes a wide variety of complex cardiac manifestations such as acute myopericarditis, acute coronary syndrome, congested heart failure, cardiogenic shock and cardiac arrhythmias. There are numerous proposed mechanisms of cardiac injury, including direct cellular injury, pro-inflammatory cytokine storm, myocardial oxygen-demand mismatch, and systemic inflammation causing multi-organ failure. Additionally, medications commonly used to treat COVID-19 patients have various cardiovascular side effects. We aim to provide a succinct review about the pathophysiology and cardiac manifestations of COVID-19, as well as treatment considerations and the various adaptations made to the current healthcare structure as a result of the pandemic.

COVID-19 myocarditis and long-term heart failure sequelae.

PURPOSE OF REVIEW: The clinical syndrome of coronavirus disease 2019 (COVID-19) has become a global pandemic leading to significant morbidity and mortality. Cardiac dysfunction is commonly seen in these patients, often presenting as clinical heart failure. Accordingly, we aim to provide a comprehensive review on COVID-19 myocarditis and its long-term heart failure sequelae. RECENT FINDINGS: Several suspected cases of COVID-19 myocarditis have been reported. It is often not clear if the acute myocardial dysfunction is caused by myocarditis or secondary to generalized inflammatory state of cytokine release or microvascular thrombotic angiopathy. Ischemia may also need to be ruled out. Regardless, myocardial dysfunction in these patients is associated with poor overall prognosis. Laboratory testing, echocardiography, cardiac magnetic resonance imaging, and even endomyocardial biopsy may be needed for timely diagnosis. Several treatment strategies have been described, including both supportive and targeted therapies. SUMMARY: COVID-19 can cause a spectrum of ventricular dysfunction ranging from mild disease to fulminant myocarditis with hemodynamic instability. Future research is needed to understand the true prevalence of COVID-19 myocarditis, as well as to better define various diagnostic protocols and treatment strategies.

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients with Left Ventricular Systolic Dysfunction.

PURPOSE: There is a paucity of comparative data examining the optimal revascularization strategy in patients with left ventricular systolic dysfunction (LVD). METHODS: We performed an aggregate data meta-analysis of clinical outcomes comparing percutaneous coronary intervention (PCI) versus coronary artery bypass (CABG) in patients with LVD (left ventricle ejection fraction (LVEF) of ≤ 40%), using the random effects model. Effects size is reported as odds ratio (OR) and a 95% confidence interval. Outcomes included all-cause mortality, myocardial infarction, stroke, repeat revascularization, and a composite of major adverse cardiac and cerebrovascular events (MACCE) at 30-day, 3-year, and long-term (6.3 ± 0.9 years) follow-ups. Seventeen studies (16 observational, 1 randomized) and 18,599 patients (CABG 9651; PCI 8948) were included. RESULTS: PCI and CABG had comparable all-cause mortality at 30 days (OR 0.78, 95% CI 0.49-1.23) and 3 years (OR 1.05, 95% CI 0.91-1.21); however, PCI was associated with increased long-term morality after a mean follow-up of 6.3 ± 0.9 years (31.6% vs. 24.3%, OR 1.41, 95% CI 1.21-1.64). A similar mortality trend was observed in the subgroup of patients with EF ≤ 35%. PCI had a higher rate of repeat revascularization at 3-year and long-term follow-ups. The long-term rates of stroke and MI were comparable. PCI, on the other hand, had lower rates of stroke at 30-day and 3-year follow-ups. CONCLUSION: CABG was associated with lower rates of long-term mortality and revascularization but higher rate of upfront stroke in patients with LVD. However, the data included consisted predominantly of observational studies, highlighting the paucity and need for randomized trials.

Oral Antiplatelet Therapy After Acute Coronary Syndrome: A Review.

IMPORTANCE: Acute coronary syndrome (ACS) is a major cause of morbidity and mortality in the United States with an annual incidence of approximately 1 million. Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) reduces cardiovascular event rates after ACS. OBSERVATIONS: In 2016, the updated guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommended aspirin plus a P2Y12 inhibitor for at least 12 months for patients with ACS. Since these recommendations were published, new randomized clinical trials have studied different regimens and durations of antiplatelet therapy. Recommendations vary according to the risk of bleeding. If bleeding risk is low, prolonged DAPT may be considered, although the optimal duration of prolonged DAPT beyond 1 year is not well established. If bleeding risk is high, shorter duration (ie, 3-6 months) of DAPT may be reasonable. A high risk of bleeding traditionally is defined as a 1-year risk of serious bleeding (either fatal or associated with a ≥3-g/dL drop in hemoglobin) of at least 4% or a risk of an intracranial hemorrhage of at least 1%. Patients at higher risk are 65 years old or older; have low body weight (BMI <18.5), diabetes, or prior bleeding; or take oral anticoagulants. The newest P2Y12 inhibitors, prasugrel and ticagrelor, are more potent, with high on-treatment residual platelet reactivity of about 3% vs 30% to 40% with clopidogrel and act within 30 minutes compared with 2 hours for clopidogrel. Clinicians should avoid prescribing prasugrel to patients with a history of stroke or transient ischemic attack because of an increased risk of cerebrovascular events (6.5% vs 1.2% with clopidogrel, P = .002) and should avoid prescribing it to patients older than 75 years or who weigh less than 60 kg. The ISAR-REACT-5 trial found that prasugrel reduced rates of death, myocardial infarction, or stroke at 1 year compared with ticagrelor among patients with ACS undergoing percutaneous coronary intervention (9.3% vs 6.9%, P = .006) with no significant difference in bleeding. Recent trials suggested that discontinuing aspirin rather than the P2Y12 inhibitor may be associated with better outcomes. CONCLUSIONS AND RELEVANCE: Dual antiplatelet therapy reduces rates of cardiovascular events in patients with acute coronary syndrome. Specific combinations and duration of dual antiplatelet therapy should be based on patient characteristics-risk of bleeding myocardial ischemia.

Obesity and the paradox of mortality and heart failure hospitalization in heart failure with preserved ejection fraction.

BACKGROUND: Limited data exist on the association of obesity with both hospitalization and mortality in patients with heart failure with preserved ejection fraction (HFpEF), especially in the real-world ambulatory setting. We hypothesized that increasing body-mass index (BMI) in ambulatory heart failure with preserved ejection fraction would have a protective effect on these patients leading to decreased mortality and hospitalizations. METHODS: We studied the relationship between BMI and the time to all-cause mortality, time to heart failure (HF) hospitalization, and time to all-cause hospitalization over a 2-year follow-up in a national cohort of 2501 ambulatory HFpEF patients at 153 Veterans Affairs medical centers. RESULTS: Compared with normal BMI, overweight (HR 0.72; 95% CI 0.57-0.91), obesity class I (HR 0.59; 95% CI 0.45-0.77), obesity class II (HR 0.56; 95% CI 0.40-0.77), and obesity class III (HR 0.53; 95% CI 0.36-0.77) were associated with improved survival after adjustment for demographics and comorbidities. In contrast, the time to HF hospitalization showed an inverse relationship, with shorter time to HF hospitalization with increasing BMI compared with normal BMI; overweight (adjusted HR 1.30; 95% CI 0.88-1.90), obesity class I (HR 1.57; 95% CI 1.05-2.34), obesity class II (HR 1.79; 95% CI 1.15-2.78), and obesity class III (HR 1.96; 95% CI 1.23-3.12). However, time to first all-cause hospitalization was not significantly different by BMI groups. CONCLUSIONS: In a large, national ambulatory HFpEF cohort, despite the presence of the obesity paradox with respect to survival, increasing BMI was independently associated with an increased risk of HF hospitalization and similar risk of all-cause hospitalization. Future longer-term prospective trials evaluating the safety and efficacy of weight loss on morbidity and mortality, in patients with severe obesity and HFpEF are needed.

Premature Atherosclerotic Cardiovascular Disease: What Have We Learned Recently?

PURPOSE OF REVIEW: In contrast to patients with non-premature atherosclerotic cardiovascular disease (ASCVD), patients with premature ASCVD have not observed a similar decline in cardiovascular mortality and recurrent adverse events. We sought to review the underlying risk factors, potential gaps in medical management, associated outcomes, and tools for risk prognostication among patients with premature ASCVD. RECENT FINDINGS: In addition to traditional cardiovascular risk factors (i.e., diabetes, familial hypercholesterolemia), non-traditional risk factors such as chronic inflammatory conditions, recreational drug use, genetics, and pregnancy-related complications play a key role in development and progression of premature ASCVD. Patients with premature ASCVD, and especially women, receive less optimal medical management as compared to their non-premature counterparts. There is an increasing prevalence of cardiovascular risk factors among young adults. Hence, this population remains at an elevated risk for premature ASCVD and subsequent adverse cardiovascular events. Future studies evaluating different risk assessment tools and focusing on young patients across all three major domains of ASCVD are needed.

A Blockchain-Based Multi-Mobile Code-Driven Trust Mechanism for Detecting Internal Attacks in Internet of Things.

A multitude of smart things and wirelessly connected Sensor Nodes (SNs) have pervasively facilitated the use of smart applications in every domain of life. Along with the bounties of smart things and applications, there are hazards of external and internal attacks. Unfortunately, mitigating internal attacks is quite challenging, where network lifespan (w.r.t. energy consumption at node level), latency, and scalability are the three main factors that influence the efficacy of security measures. Furthermore, most of the security measures provide centralized solutions, ignoring the decentralized nature of SN-powered Internet of Things (IoT) deployments. This paper presents an energy-efficient decentralized trust mechanism using a blockchain-based multi-mobile code-driven solution for detecting internal attacks in sensor node-powered IoT. The results validate the better performance of the proposed solution over existing solutions with 43.94% and 2.67% less message overhead in blackhole and greyhole attack scenarios, respectively. Similarly, the malicious node detection time is reduced by 20.35% and 11.35% in both blackhole and greyhole attacks. Both of these factors play a vital role in improving network lifetime.

Swallowing-induced Supraventricular Tachyarrhythmia.

Swallowing-induced supraventricular tachyarrhythmia is an extremely rare entity with unclear pathophysiology. A 55-year-old man presented with a 2-year history of worsening presyncopal symptoms triggered only by drinking liquids of any temperature. Results of a physical examination were unremarkable except for reproducible atrial tachycardias to 180 to 210 beats/minute documented on rhythm strips when the patient was given water to drink. He underwent radiofrequency ablation with complete resolution of symptoms. We reviewed all 43 published cases of swallowing-induced supraventricular tachyarrhythmia in the English-language medical literature. We found only one other reported case induced only by drinking liquids. Radiofrequency ablation appears to be the treatment of choice.

Obesity and Cardiovascular Disease: a Risk Factor or a Risk Marker?

In the USA, 69 % of adults are either overweight or obese and 35 % are obese. Obesity is associated with an increased incidence of various cardiovascular disorders. Obesity is a risk marker for cardiovascular disease, in that it is associated with a much higher prevalence of comorbidities such as diabetes, hypertension, and metabolic syndrome, which then increase the risk for cardiovascular disease. However, in addition, obesity may also be an independent risk factor for the development of cardiovascular disease. Furthermore, although obesity has been shown to be an independent risk factor for several cardiovascular diseases, it is often associated with improved survival once the diagnosis of the cardiovascular disease has been made, leading to the term "obesity paradox." Several pathways linking obesity and cardiovascular disease have been described. In this review, we attempt to summarize the complex relationship between obesity and cardiovascular disorders, in particular coronary atherosclerosis, heart failure, and atrial fibrillation.

Clinical Significance of Upsloping ST Depression on Resting Electrocardiogram.

INTRODUCTION: Upsloping ST depression is generally not associated with myocardial ischemia, yet there have been published reports that suggest otherwise. CASE HISTORY: A 34-year-old pregnant female presented with chest pain and palpitations. She was found to have supraventricular tachycardia, which resolved with intravenous adenosine. Few minutes later her ECG showed upsloping ST depression in leads V4-V6 that persisted for 1 hour after the resolution of the tachycardia. The patient was discharged in stable condition with outpatient follow-up. CONCLUSION: Upsloping ST depression in resting electrocardiogram may indicate cardiac ischemia in the presence of active cardiac symptoms. In the absence of ongoing symptoms however, it may be secondary to conditions other than ischemia.

Clinical implications of combination proton pump inhibitor and triple therapies in patients with atrial fibrillation following percutaneous intervention: a guide for clinicians.

INTRODUCTION: Patients on systemic oral anticoagulation with vitamin K antagonists (VKA) or non-vitamin K oral anticoagulants (NOAC) often require triple therapy following percutaneous coronary intervention, substantially increasing the risk of bleeding. Gastroprotective agents like proton pump inhibitors (PPI) are often employed to mitigate this risk, despite potential competitive inhibition between P2Y12-receptor inhibitors, NOACs, and VKAs. While the interactions and clinical outcomes of PPIs and DAPT have been frequently explored in literature, not many studies have evaluated the same outcomes for triple therapy. AREAS COVERED: This comprehensive narrative review of three studies on PPIs and triple from the PubMed/MEDLINE database supplemented by 23 other relevant studies aims to use the available literature to analyze the potential interactions between PPIs and triple therapy while shedding light on their mechanisms, clinical implications, and areas for optimization. EXPERT OPINION: If triple therapy is indicated following PCI, then patients at high-risk for bleeding may benefit from transition to apixaban and a PPI to lower the risk of gastrointestinal bleeding. More research is needed to determine the role of PPIs in triple therapies in prevention of gastrointestinal bleeding or potentiation of other adverse outcomes.

Stealing from the Heart: A Rare Case of Chest Pain Post-Coronary Artery Bypass Grafting.

A 70-year-old veteran with prior triple vessel coronary artery bypass grafting (CABG) presented with exertional chest pain. His work-up revealed > 40 mm Hg bilateral upper extremity blood pressure difference. Chest computed tomography and invasive angiography revealed severe stenosis at the ostium of the left subclavian artery, proximal to the origin of the left internal mammary artery to left anterior descending artery graft (LIMA-LAD). A diagnosis of coronary subclavian steal syndrome (CSSS) was made, and carotid-subclavian bypass was performed. This case outlines when to suspect CSSS, an approach to its diagnosis, and the importance of its timely management.

Trends and Outcomes in Patients With Coronary Artery Disease Undergoing TAVR: Insights From VA CART.

Background: Obstructive coronary artery disease (CAD) is common in patients with severe symptomatic aortic stenosis. The management and impact of obstructive CAD in patients undergoing transcatheter aortic valve replacement (TAVR) have not been fully evaluated. We aimed to determine the patient characteristics and clinical outcomes among veterans undergoing TAVR with and without obstructive CAD and to determine temporal trends and association of pre-TAVR percutaneous coronary intervention (PCI) with clinical outcomes. Methods: We identified all patients who underwent TAVR from 2012 to 2021 in the VA Health Care System. The sample population was divided into patients with and without obstructive CAD and further stratified by coronary intervention status 1 year prior to TAVR. The primary outcome was 1-year all-cause mortality, and the secondary outcome was major bleeding. Results: During the study period, 759 patients underwent TAVR, and 282 (37%) had obstructive CAD. Obstructive CAD was associated with higher 1-year mortality (15.6% vs 7.1%; P < .01) after TAVR. The rate of PCI prior to TAVR increased from 2012 until 2016, after which it steadily declined such that 144 patients (51%) underwent PCI pre-TAVR during the entire study period. There was no difference in 1-year mortality (16.0% vs 15.2%; P = .89) or bleeding (16.7% vs 12.3%; P = .33) between patients who underwent or did not undergo pre-TAVR PCI. Conclusions: Among veterans undergoing TAVR, the presence of obstructive CAD is associated with higher mortality though pre-TAVR coronary intervention is not associated with improved outcomes. Further studies could identify a subset of patients who may benefit from coronary revascularization prior to TAVR.

Use of Preventive Cardiovascular Health Care Among Asian American Individuals: A National Health Interview Survey Study.

The risk of atherosclerotic cardiovascular disease (ASCVD) varies across Asian Americans. Heterogeneity in preventive health care use may have a role in health disparity across Asian American populations. We included 318,069 White, Chinese, Asian Indian, Filipino, and 'other Asian' (Japanese, Korean, and Vietnamese) participants with and without a self-reported history of ASCVD or ASCVD risk factors (including hypertension, hypercholesterolemia, and diabetes) from 2006 to 2018 National Health Interview Survey (NHIS). We used multivariable logistic regression models adjusted for age, sex, US birth, education, insurance coverage, and a comorbidity score to assess the association between Asian American race/ethnicity and annual health care use. Adjusted odds ratios (aOR) with 95% confidence intervals were reported. Of the total, 187,093 participants did not report ASCVD or ASCVD risk factors (mean age, 40.2±0.1 years; 52% women), and 130,976 participants reported ASCVD or ASCVD risk factors (mean age, 58.3±0.9 years; 49.5% women). Compared with White individuals, among the group without ASCVD or ASCVD risk factors (N=187,093), 'other Asian' adults were less likely to visit a general practitioner (aOR=0.80, 0.72-0.89), or check blood pressure (aOR=0.77, 0.66-0.89), blood cholesterol (aOR=0.80, 0.70-0.92), and fasting blood sugar (aOR=0.73, 0.63-0.84). Among participants with ASCVD or ASCVD risk factors (N=130,976), Asian Indian adults were more likely to visit a general practitioner (aOR=1.29, 1.01-1.66), or check blood pressure (aOR=1.27, 0.83-1.96), blood cholesterol (aOR=1.46, 1.00-2.15), and fasting blood sugar (aOR=1.49, 1.11-1.99). Annual preventive health care use is heterogeneous across the Asian American populations.

Readmission in patients undergoing percutaneous patent foramen ovale closure in the United States.

Current estimates suggest that a patent foramen ovale (PFO) may exist in up to 25% of the general population and is a potential risk factor for embolic, ischemic stroke. PFO closure complications include bleeding, need for procedure-related surgical intervention, pulmonary emboli, device malpositioning, new onset atrial arrhythmias, and transient atrioventricular block. Rates of PFO closure complications at a national level in the Unites States remain unknown. To address this, we performed a contemporary nationwide study using the 2016 and 2017 Nationwide Readmissions Database (NRD) to identify patterns of readmissions after percutaneous PFO closure. In conclusion, our study showed that following PFO closure, the most common complications were atrial fibrillation/atrial flutter followed by acute heart failure syndrome, supraventricular tachycardia and acute myocardial infarction.

Dual Antiplatelet Therapy: A Concise Review for Clinicians.

Dual antiplatelet therapy (DAPT) combines two antiplatelet agents to decrease the risk of thrombotic complications associated with atherosclerotic cardiovascular diseases. Emerging data about the duration of DAPT is being published continuously. New approaches are trying to balance the time, benefits, and risks for patients taking DAPT for established cardiovascular diseases. Short-term dual DAPT of 3-6 months, or even 1 month in high-bleeding risk patients, is equivalent in terms of efficacy and effectiveness compared to long-term DAPT for patients who experienced percutaneous coronary intervention in an acute coronary syndrome setting. Prolonged DAPT beyond 12 months reduces stent thrombosis, major adverse cardiovascular events, and myocardial infarction rates but increases bleeding risk. Extended DAPT does not significantly benefit stable coronary artery disease patients in reducing stroke, myocardial infarction, or cardiovascular death. Ticagrelor and aspirin reduce cardiovascular events in stable coronary artery disease with diabetes but carry a higher bleeding risk. Antiplatelet therapy duration in atrial fibrillation patients after percutaneous coronary intervention depends on individual characteristics and bleeding risk. Antiplatelet therapy is crucial for post-coronary artery bypass graft and transcatheter aortic valve implantation; Aspirin (ASA) monotherapy is preferred. Antiplatelet therapy duration in peripheral artery disease depends on the scenario. Adding vorapaxar and cilostazol may benefit secondary prevention and claudication, respectively. Carotid artery disease patients with transient ischemic attack or stroke benefit from antiplatelet therapy and combining ASA and clopidogrel is more effective than ASA alone. The optimal duration of DAPT after carotid artery stenting is uncertain. Resistance to ASA and clopidogrel poses an incremental risk of deleterious cardiovascular events and stroke. The selection and duration of antiplatelet therapy in patients with cardiovascular disease requires careful consideration of both efficacy and safety outcomes. The use of combination therapies may provide added benefits but should be weighed against the risk of bleeding. Further research and clinical trials are needed to optimize antiplatelet treatment in different patient populations and clinical scenarios.