Continuation of Dual-Antiplatelet Therapy Following Percutaneous Revascularization with a Drug-Eluting Stent: What Duration Is Optimal?

Dual-antiplatelet therapy (DAPT) is required after percutaneous coronary intervention with drug-eluting stents (DESs) to prevent thrombotic complications, particularly stent thrombosis (ST). However, there is still disagreement regarding the optimal duration of DAPT post-DES placement. Compared to bare metal stents, DESs are known to reduce restenosis and target vessel revascularization but may be more prone to late and very late ST due to delayed endothelialization. Several trials have suggested that longer (>12 months) DAPT reduces ischemic events but does so at the cost of increased bleeding. Other trials have demonstrated non-inferiority of shorter (3 to 6 months) DAPT compared to long-term DAPT, with fewer bleeding events. The clinical challenge is how to balance the reduced ischemic risk with increased bleeding associated with longer DAPT. Furthermore, ST is associated with multiple patient- and procedure-specific factors, thereby limiting a "one-size-fits-all" approach to determining optimal duration of DAPT. The evaluation of DAPT duration should therefore be tailored individually. We will review the data supporting current recommendations for DAPT and recent clinical trials comparing varying DAPT durations and discuss patient- and procedure-specific factors affecting the "optimal" DAPT duration.

Invasive Hemodynamic Assessment of Patients with Heart Failure and Pulmonary Hypertension.

OPINION STATEMENT: Right heart catheterization (RHC) with a pulmonary artery (PA) catheter is a minimally invasive method of obtaining hemodynamic data (e.g., right atrial and pulmonary pressures, cardiac output, pulmonary vascular resistance), which are used to diagnose and manage patients with advanced heart failure (HF), HF with preserved ejection fraction, and pulmonary hypertension (PH). Invasive hemodynamic data obtained from RHC can aid in the prognostication of HF and PH patients and are important in guiding decisions of implanting mechanical circulatory support devices and listing patients for heart and/or lung transplantation. The basis of RHC has also paved the way for implantable hemodynamic devices to monitor pulmonary artery pressures in the outpatient setting, which can reduce rates of HF-related hospitalizations. We will discuss the utility of PA catheters in the diagnosis and management of the aforementioned disease states, the role of implantable hemodynamic monitors, and the complications associated with RHC procedures.

Gender Differences in In-Hospital Outcomes After Coronary Artery Bypass Grafting.

Women historically have a greater risk of operative mortality than men after coronary artery bypass grafting (CABG). There is paucity of contemporary data in gender outcomes of surgical revascularization and understanding modifiable factors that contribute to gender differences are critical for quality improvement and practice change. We, therefore, sought to examine whether the gender gap in CABG outcomes is closing in the contemporary era by conducting a retrospective analysis from the Nationwide Inpatient Sample database from 2003 to 2012. We included all patients who underwent isolated CABG surgery (n = 2,272,998; female n = 623,423 [27.4%]; male n = 1,649,575 [72.6%]). The annual rate of CABG surgeries decreased by 53.7% in men and 57.8% in women over the 10-year study period. Although internal mammary artery use in women was less frequent than in men in 2003 (77.4% vs 81.9%, p <0.001), a significant uptrend closed this gap by 2012 (86.2% vs 87.0%, ptrend 0.003). Overall, unadjusted in-hospital mortality was greater in women (3.2% vs 1.8%, p <0.001). Female gender remained an independent predictor of mortality after multivariate adjustment (odds ratio 1.40, 95% CI 1.36 to 1.43, p <0.001) across all age groups. However, in-hospital mortality decreased at a faster rate in women (3.8% to 2.7%, RR -29.1%, ptrend 0.002) than in men (2.2% to 1.6%, RR -25.7%, ptrend <0.001) from 2003 to 2012. In conclusion, CABG rates in the United States are decreasing over time, yet in-hospital mortality continues to improve. Women have worse in-hospital outcomes than men; however, the gender gap is slowly closing.