Evaluating the safety and effectiveness of direct oral anticoagulants compared with warfarin in very elderly patients with atrial fibrillation with and without low bodyweight.

BACKGROUND: Limited data exist on the safety and effectiveness of using direct oral anticoagulants (DOACs) in patients with atrial fibrillation aged 80 years or more with and without low bodyweight (LBW). OBJECTIVES: We aimed to evaluate the safety and effectiveness of using DOACs in this population compared with warfarin. METHODS: This retrospective active comparator new-user cohort study included veteran patients with atrial fibrillation who were newly initiated on either warfarin or DOACs between January 1, 2015, and January 1, 2021. The primary outcome was incidence of major bleeding and ischemic stroke. All outcomes were compared between treatment groups in 2 propensity score-matched cohorts of patients aged 80 years older with (AW) and without LBW (age-only cohort). Cox proportional hazard models were used to estimate adjusted hazard ratios (aHRs). RESULTS: Matched AW and age-only cohorts included 493 and 11 909 patients, respectively, in each of the DOAC and warfarin exposure groups. Greater than 90% were male, with a mean age of ∼87 years. The rate of major bleeding was lower in the DOAC group compared with warfarin in both the AW (aHR, 0.63; 95% CI, 0.46-0.87) and age-only cohorts (aHR, 0.58; 95% CI, 0.49-0.77). A significantly lower rate of ischemic stroke occurred in the DOAC group compared with warfarin in the AW cohort (aHR, 0.62; 95% CI, 0.45-0.84) and age-only cohort (aHR, 0.63; 95% CI, 0.58-0.68). CONCLUSION: DOAC use was associated with lower risk of major bleeding and ischemic stroke compared with warfarin in patients aged 80 years or older with and without LBW.

Impact of Pharmacist-Led Heart Failure Clinic on Optimization of Guideline-Directed Medical Therapy (PHARM-HF).

This prospective study included patients with heart failure (HF) with reduced ejection fraction (HFrEF) with LVEF < = 40% to evaluate the impact of pharmacist on guideline directed medical therapy (GDMT). The primary outcome was to compare proportion of triple GDMT achieved for Angiotensin-Converting-Enzyme-Inhibitors (ACEI)/Angiotensin-Receptor-Blockers (ARB)/Angiotensin-Receptor-Neprilysin-Inhibitors (ARNI), beta-blockers, aldosterone antagonists (AA), and quadruple GDMT which in additional to triple therapy, included Sodium glucose co-transporter 2 inhibitor (SGLT2i) at 90-day post-enrollment compared to baseline. Secondary endpoints included achieving target and/or maximally tolerated ACEI/ARB/ARNI and beta-blockers combined and individually as well as SGLT2i and AA GDMT at 90-day post-enrollment compared to baseline. We also compared combined and individual HF-related hospitalization/emergency room (ER) visits 90 days pre-/post-enrollment. Of the total 974 patients screened, 80 patients seen at least once in the heart failure medication titration clinic (HMTC) were included in the analysis. Median (IQR) age was 71 (57-69) years with majority white male. There was a significant improvement in the proportion of patients who achieved quadruple GDMT (p = 0.001) and triple GDMT (p-value = 0.020) at 90-day post-enrollment compared to baseline. The secondary GDMT outcomes were also significantly increased at 90 days post-enrollment compared to baseline. Significant difference in mean as well as proportion of combined HF-related hospitalization/ER-visits was found 90 days pre-/post-enrollment (p = 0.047). Our study found that pharmacist's intervention increased the proportion of patients who achieved GDMT at 90 days.

Association of Diastolic Dysfunction with Reduced Cardiorespiratory Fitness in Adults Living with HIV.

Despite the high prevalence of diastolic dysfunction in adults living with HIV, the impact on cardiorespiratory fitness (CRF) is understudied. The objective of this cross-sectional study was to investigate the relationship between cardiac function and CRF in adults with HIV. Adults receiving antiretroviral therapy with no history of coronary artery disease (CAD) or heart failure were eligible to participate. Cardiac function was assessed by resting Doppler echocardiography. CRF was measured by oxygen utilization at peak exercise (VO2peak). The majority of participants were African American (86%) and male (97%) with a mean [standard deviation (SD)] age of 56.6 (7.1) years and median CD4 lymphocyte count of 492 cells/mL. The mean (SD) VO2peak was 26.1 (5.5) mL/(kg·min). Age, diabetes, hypertension, and hemoglobin were associated with VO2peak. Overall, diastolic dysfunction was present in 38% and was associated with lower VO2peak (p < 0.05). VO2peak was lower among those with impaired myocardial relaxation (e' <8 cm/s) compared with normal relaxation [mean ± SE mL/(kg·min), 25.2 ± 0.6 vs. 27.7 ± 0.9, p < 0.05]. Adjusted for age and clinical factors, each unit increase in left ventricular relaxation (E/A) was associated with an average 4.4 mL/(kg·min) higher VO2peak, representing more than one metabolic equivalent. We conclude that diastolic dysfunction is independently associated with clinically significant low CRF in adults with HIV and no history of CAD or heart failure. These results highlight the importance of recognizing diastolic dysfunction in individuals living with HIV regardless of their cardiovascular disease history.

Changes With Lanthanum Carbonate, Calcium Acetate, and Phosphorus Restriction in CKD: A Randomized Controlled Trial.

INTRODUCTION: Abnormal phosphorus homeostasis develops early in chronic kidney disease (CKD). It is unclear if its correction results in improved clinical outcomes in non-dialysis dependent CKD. METHODS: We conducted a randomized controlled, parallel design clinical trial in 120 patients with estimated glomerular filtration rate 15 to 59 ml/min per 1.73 m2 and abnormal phosphorus homeostasis (serum phosphorus >4.6 mg/dl, parathyroid hormone [PTH] >70 pg/ml or tubular reabsorption of phosphorus [TRP] <80%). Patients were randomized to open-label lanthanum carbonate versus calcium acetate versus dietary intervention over 1 year. The co-primary outcomes were month 12 (vs. baseline) biochemical (serum phosphorus, TRP, PTH, calcium, bone-specific alkaline phosphatase [bALP], and fibroblast growth factor 23 [FGF23]) and vascular parameters (coronary artery calcium score, pulse wave velocity, and endothelial dysfunction) in all patients. Secondary outcomes were between-treatment differences in change for each parameter between month 12 and baseline. All analyses were intention to treat. RESULTS: Baseline characteristics were similar in the 3 groups. A total of 107 patients (89%) completed 12 months of follow-up. Differences were not significant at month 12 (vs. baseline) for any of the outcomes except bALP (median [25th, 75th] percentile at month 12 versus baseline: 13.8 [10.6, 17.6] vs. 15.8 [12.1, 21.1], P < .001) and FGF23 (132 [99, 216] vs. 133 [86, 189], P = .002). Changes for all outcomes were similar in the 3 arms except for PTH, which was suppressed more effectively by calcium acetate (P < .001). CONCLUSION: A 1-year intervention to limit phosphorus absorption using dietary restriction or 2 different phosphorus binders resulted in decreased bALP suggesting improved bone turnover, but no other significant changes in biochemical or vascular parameters in patients with CKD stage 3/4. (ClinicalTrials.gov: NCT01357317).

New-onset syncope in older adults: focus on age and etiology.

The authors explored the differences in clinical presentation, etiology, mortality, and recurrences of new-onset syncope in 502 patients across 3 age groups: middle-aged (36-60 years), older (61-75 years), and elderly (older than 75 years). Clinical features of syncopal episodes were similar except for more frequent presyncopal episodes in patients older than 75 years. Yield of diagnostic tests was similarly low except for higher incidence of positive tilt-table test (60%) in older patients. Syncope remained unexplained more frequently in the elderly (54% vs 37% in middle-aged and 43% in older adults, P=.01). Syncope recurrence was higher in the middle-aged and elderly groups. Overall mortality for the 3 age groups was similar to that recorded in the general population after adjustment for age and comorbidities. Etiology of syncope was not associated with age- and comorbidity-adjusted all-cause mortality. Cardiovascular mortality was significantly higher in patients with cardiogenic syncope (adjusted hazard ratio, 2.44; P=.044).

Cost-effectiveness of the radial versus femoral artery approach to diagnostic cardiac catheterization.

BACKGROUND: The radial approach to cardiac catheterization is increasingly popular due to shorter procedural and recovery times and greater patient comfort. METHODS: Comparative cost analysis between radial or femoral (with or without closure device) approaches were performed. RESULTS: Radial (R), femoral (F), and femoral with a closure device (F +/- C) approaches were used in 70, 62 and 49 consecutive cases, respectively. Group R had higher access equipment cost (93.0 dollars +/- 9.5 vs. 40.5 dollars) in group F (p < 0.001), but lower catheter cost (19.7 dollars +/- 12.7 vs. 31.1 dollars +/- 9.3; p < 0.001) than Group F, and lower contrast cost (26.9 dollars +/- 17.0 vs. 42.9 dollars +/- 25.0) in Group F +/- C (p < 0.001). There was a lower postprocedure recovery cost (185.2 dollars +/- 52.7) in Group R compared to 337.5 dollars +/- 59.0 in Group F (p < 0.001) and 208 dollars +/- 70.4 in Group F +/- C (p < 0.001), with a median recovery time of 126.0 +/- 36.0 minutes in group R vs. 240.0 +/- 42.0 minutes, and 150.0 +/- 48.0 minutes in groups F and F +/- C, respectively (both p < 0.05). The total variable procedural cost, which includes approach-dependent equipment and recovery room stay, was significantly lower in the Radial group than in the Femoral group (369.5 dollars +/- 74.6 vs. 446.9 dollars +/- 60.2 and 553.4 dollars +/- 81.0; p < 0.001). CONCLUSION: The radial artery approach to diagnostic cardiac catheterization is clearly more cost effective than the femoral approach, with or without the use of a femoral closure device.

Outcomes of unexplained syncope in the elderly.

The objective of this study was to determine whether syncope of unknown etiology (SUE) influences mortality in the elderly. Patients with SUE at 65 years or older were identified retrospectively and their outcomes were compared with an age-, sex-, and comorbidity-matched group of patients drawn from the same population. All-cause 3-year mortality was analyzed using the Kaplan-Meier method and the log-rank test. SUE was identified in 150 of 304 patients (49%) with syncope. Patients with SUE and controls experienced mortality rates (1/1000 person-years [95% confidence interval]) of 147.8 (112.6-193.9) and 153.4 (117.5-200.3), P=.7, respectively. Of all the recorded characteristics of SUE, only the inpatient status was associated with higher all-cause mortality (Cox model adjusted hazard ratio [95% confidence interval] of inpatients vs outpatients with SUE: 2.2 [1.1-4.1], P=.017). New-onset SUE is not an independent predictor of mortality in elderly patients.

Nonemergent percutaneous coronary interventions in a veterans affairs medical center without onsite cardiac surgery.

BACKGROUND: Percutaneous coronary intervention (PCI) performed in centers without onsite cardiac surgery remains controversial. Advances in PCI techniques and medical therapy have markedly decreased postprocedural complications. Our aim was to assess the efficacy and safety of performing PCI in the Veterans Affairs patient population in a hospital without onsite cardiac surgery. METHODS: We prospectively evaluated 401 consecutive patients who underwent elective PCI or PCI after admission for acute coronary syndrome. Patients who had ST-elevation myocardial infarction or were hemodynamically unstable were classified as emergent and had their PCI performed elsewhere and were therefore excluded from our analysis. Our cardiac surgery backup was a community hospital 8 miles away. RESULTS: The patient's mean age was 65.6 +/- 10 years, and most were men (99.5%). Patients had high-risk clinical and angiographic profiles, with diabetes mellitus in 44%, prior myocardial infarction in 41%, comorbid conditions in 45% and type B or C angiographic lesions in 83%. Of 401 patients, 338 (84%) received a stent, and 86 (21%), a drug eluting stent. Percutaneous coronary intervention success rate was 97%. There were no periprocedural or inhospital deaths, and no patients required emergency transfer for cardiac surgery. At 1 and 6 months of follow-up, total mortality was 1.5% and 3.5%, respectively; target vessel revascularization rate was 0% and 1.7%. CONCLUSIONS: Nonemergent PCI can be performed effectively and safely in patients with higher clinical and angiographic risk without onsite backup cardiac surgery. This has significant implications for most hospitals that have an invasive but not an interventional program.