Search

The ideal antithrombotic therapy post transcatheter aortic valve replacement (TAVR) remains uncertain. We performed a network meta-analysis of RCTs to report the outcomes with various antithrombotic strategies to determine the optimal therapy. A systematic search of the PubMed/Medline and Cochrane databases was performed through January 6, 2022. The primary outcome was stroke and the secondary outcomes were major/life-threatening bleeding, myocardial infarction, all-cause mortality, and cardiac mortality. A network meta-analysis was conducted with a random-effects model. All analysis was carried out using R version 4.0.3. Six RCTs were included in the final analysis. SAPT when compared with DAPT was associated with a reduced risk of major or life-threatening bleeding [OR: 0.42; 95% CI: 0.25-0.70]. Other antithrombotic strategies were associated with similar odds of major and life-threatening bleeding post TAVR compared with DAPT. There was no difference in the incidence of stroke, myocardial infarction, all-cause and cardiac mortality between the various antithrombotic strategies post TAVR. The present analysis reported SAPT as the preferred antithrombotic regimen post TAVR compared with other regimens in patients who do not have other indications for anticoagulation. Additional studies such as ADAPT-TAVR, CLOE and ATLANTIS trials will further add to our understanding of the adequate antithrombotic regimen post TAVR in patients with otherwise no indication for anticoagulation. [ABSTRACT FROM AUTHOR]

The article presents the case study of a 70-year-old man who visited the hospital complaining about headache along with double vision, and was diagnosed with Garcin's syndrome possibly leading to nasopharyngeal carcinoma.

Background: The role of revascularization in patients with stable ischemic heart disease (SIHD) has been controversial, more so in the present era of drug-eluting stents.Aims: To examine the absolute risk difference (ARD) between revascularization plus optimal medical therapy (OMT) versus OMT alone among patients with SIHD using Bayesian approach.Methods: PubMed/MEDLINE and Cochrane citation indices were utilized to identify randomized controlled trials (RCTs) through March 31, 2020. Among trials comparing initial revascularization plus OMT with initial OMT alone, revascularization arm must have comprised >50% of patients receiving either percutaneous or surgical revascularization, and >50% of patients must have received aspirin and statin as OMT in both arms.Results: Seven RCTs (12,494) were included in the final analysis. The ARD of all-cause mortality for revascularization with respect to OMT was centred at -0.002 (95% CrI: -0.01; 0.01, Tau: 0.01, 67% probability of ARD of revascularization vs. OMT < 0). The ARD for cardiac mortality was centred at -0.0025 (95%CrI: -0.01; 0.01, Tau: 0.01, 77% probability of ARD of revascularization vs. OMT < 0). The ARD for MI was -0.02 (95% CrI: -0.06; 0.00, Tau: 0.02, 97% probability of ARD for revascularization vs. OMT < 0). There was 96% probability of ARD for unstable angina with revascularization vs. OMT < 0, 4.5% probability of ARD for freedom from angina with revascularization vs. OMT < 0, and 6% probability of ARD for stroke with revascularization vs. OMT < 0.Conclusions: Bayesian analysis demonstrated minimal probability of difference in all-cause mortality and cardiac mortality in patients with SIHD who underwent revascularization compared with OMT alone. However, revascularization was associated with lower probability of MI, unstable angina, and increased freedom from angina, but a higher risk of stroke compared with OMT alone.Prospero: The protocol of this systematic review and meta-analysis was registered in PROSPERO [CRD42020160540]. [ABSTRACT FROM AUTHOR]

Background: End-stage kidney disease (ESKD) is commonly associated with critical limb-threatening ischemia (CLTI) and frailty. Yet there are no specific tools to predict outcomes of CLTI in ESKD, particularly those that incorporate frailty. We aimed to assess the utility of the medical record-based Hospital Frailty Risk (HFR) score in predicting outcomes of CLTI in ESKD., Methods and Results: We identified patients with ESKD diagnosed with CLTI from the US Renal Data System from 2015 to 2018. These patients were categorized into 3 frailty risk groups on the basis of their HFR scores: low (<5), intermediate (5-10), high-risk (>10), and on the basis of whether they underwent revascularization (endovascular revascularization [ER]/surgical revascularization [SR]) or not (no revascularization). Primary outcomes of interest included in-hospital composite of death or major amputation and in-hospital death. We included 49 454 eligible patients, with ER/SR cohort including 19.8% (n=9777). A total of 88.4% (ER/SR) and 90.0% (no revascularization) were frail on the HFR scale. We found a nonlinear association between HFR score and in-hospital adverse outcomes. In both cohorts, intermediate and high-risk HFR scores were associated with greater risk of in-hospital death (high-risk, ER/SR: odds ratio, 2.7 [95% CI, 1.6-4.8]; P <0.0001; no revascularization: odds ratio, 7.8 [95% CI, 5.3-11.6]; P <0.01) and composite of in-hospital major amputation or death (high-risk, ER/SR: odds ratio, 2.4 [95% CI, 1.9-3.1]; P <0.0001; no revascularization: odds ratio, 1.7 [95% CI, 1.5-1.9]; P <0.0001)., Conclusions: The HFR score can predict risk of in-hospital death and composite of death or major amputation in patients with ESKD and CLTI. Further data are needed to determine the utility of the HFR score in this population.

There is limited evidence for the role of intravascular ultrasound (IVUS) in patients who underwent peripheral vascular intervention (PVI). We conducted retrospective cohort study utilizing the Healthcare Cost and Utilization Project-Agency for Healthcare Research and Quality National Readmission database to delineate outcomes in IVUS-guided PVI versus non-IVUS-guided PVI. The present study utilized National Readmission database between January 1, 2016, and December 31, 2019. We identified patients who underwent endovascular intervention for peripheral artery disease using relevant International Classification of Diseases, Tenth Revision, Procedural Coding System. The cohort was divided based on the use of IVUS during the procedure. The primary outcome was major amputation at 6 months after index hospitalization. Measured confounders were matched using propensity score inverse probability of treatment weighing method. We further performed a subgroup analysis based on disease severity, location of intervention, device, and procedure. A total of 434,901 hospitalizations were included in the present analysis. PVI with IVUS compared with no IVUS had similar risk of amputation at 6 months (195 of 8,939 [2.17%] vs 10,404 of 384,003 [2.71%]), hazard ratio 0.98, CI 0.77 to 1.25. Further, there was no difference in the rates of secondary outcomes. On subgroup analysis, amputation rates were significantly lower in patients with rest pain, in iliac intervention, or patients who underwent drug-eluting stent implantation with the use of IVUS compared with no IVUS. This nationwide observational study showed that there was no difference in major amputation rates with the use of IVUS in patients who underwent PVI. However, in subgroup of patients with rest pain, iliac intervention or drug-eluting stent implantation IVUS use was associated with significantly lower major amputation rates., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The 2019 American College of Cardiology and American Heart Association guidelines regarding low-dose aspirin in the primary prevention of atherosclerotic cardiovascular disease (ASCVD) indicate an increased risk of bleeding without a net benefit. The coronary artery calcium (CAC) score could be used to guide aspirin therapy in high-risk patients without an increased risk of bleeding. With this systematic review, we aimed to analyze studies that have investigated the role of CAC in primary prevention with aspirin. A total of 4 relevant studies were identified and the primary outcomes of interest were bleeding events and major adverse cardiac events. The outcomes of interest were stratified into 3 groups based on CAC scoring: 0, 1 to 99, and ≥100. A study concluded from 2,191 patients that with a low bleeding risk, CAC ≥100, and ASCVD risk ≥5% aspirin confers a net benefit, whereas patients with a high bleeding risk would experience a net harm, irrespective of ASCVD risk or CAC. All other studies demonstrated net benefit in patients with CAC ≥100 with a clear benefit. CAC scores correspond to calcified plaque in coronary vessels and are associated with graded increase in adverse cardiovascular events. Our review has found that in the absence of a significant bleeding risk, increased ASCVD risk and CAC score corelate with increased benefit from aspirin. A study demonstrated a decrease in the odds of myocardial infarction from 3 to 0.56 in patients on aspirin. The major drawback of aspirin for primary prevention is the bleeding complication. At present, there is no widely validated tool to predict the bleeding risk with aspirin, which creates difficulties in accurately delineating risk. Barring some discrepancy between studies, evidence shows a net harm for the use of aspirin in low ASCVD risk (<5%), irrespective of CAC score., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Adults with congenital heart disease (ACHD) have increased risk of arrhythmias warranting implantation of cardiac implantable electronic devices (CIEDs), which may parallel the observed increase in survival of ACHD patients over the past few decades. We sought to characterize the trends and outcomes of CIED implantation in the inpatient ACHD population across US from 2005 to 2019., Methods: A retrospective analysis of the Nationwide Inpatient Sample (NIS) identified 1,599,519 unique inpatient ACHD admissions (stratified as simple (85.1%), moderate (11.5%), and complex (3.4%)) using the International Classification of Diseases 9/10-CM codes. Hospitalizations for CIED implantation (pacemaker, ICD, CRT-p/CRT-d) were identified and the trends analyzed using regression analysis (2-tailed p < 0.05 was considered significant)., Results: A significant decrease in the hospitalizations for CIED implantation across the study period [3.3 (2.9-3.8)% in 2005 vs 2.4 (2.1-2.6)% in 2019, p < 0.001] was observed across all types of devices and CHD severities. Pacemaker implantation increased with each age decade, whereas ICD implantation rates decreased over 70 years of age. Complex ACHD patients receiving CIED were younger with a lower prevalence of age-related comorbidities, however, had a greater prevalence of atrial/ventricular tachyarrhythmias and complete heart block. The observed inpatient mortality rate was 1.2%., Conclusions: In a nationwide analysis, we report a significant decline in CIED implantation between 2005 and 2019 in ACHD patients. This may either be due to a greater proportion of hospitalizations resulting from other complications of ACHD or reflect a declining need for CIED due to advances in medical/surgical therapies. Future prospective studies are needed to elucidate this trend further., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The positive aspects of social interaction on health have been described often, with considerably less attention to their negative aspect. This study aimed to assess the impact of social associations on cardiovascular mortality in the United States., Methods: The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) data sets from 2016 to 2020 were used to identify death records due to cardiovascular disease in the United States population aged 15 years and older. The social association rate defined as membership associations per 10,000 population, accessed from the 2020 County Health Rankings data was used as a surrogate for social participation. All United States counties were grouped into quartiles based on their social association rate; Q1 being the lowest quartile of social association, and Q4 the highest quartile. Age-adjusted mortality rate (AAMR) was calculated for each quartile. County health factor rankings for the state of Texas were used to adjust the AAMR for baseline comorbidities of county population, using Gaussian distribution linear regression., Results: Overall, the AAMR was highest in the 4th social association rate quartile (306.73 [95% CI, 305.72-307.74]) and lowest in the 1st social association rate quartile (266.80 [95% CI, 266.41-267.20]). The mortality rates increased in a linear pattern from lowest to highest social association rate quartiles. After adjustment for the county health factor ranks of Texas, higher social association rate remained associated with a significantly higher AAMR (coefficient 15.84 [95% CI, 12.78-18.89])., Conclusions: Our study reported higher cardiovascular AAMR with higher social associations in the United States, with similar results after adjustment for County Health Rankings in the state of Texas., (© 2024. The Author(s).)

Patients with end-stage kidney disease (ESKD) on dialysis have an increased burden of coronary artery disease (CAD). This study assessed the trend and outcomes for coronary artery bypass surgery (CABG) in patients with ESKD and stable CAD. We conducted a longitudinal study using the United States Renal Data System of patients with ESKD and stable CAD who underwent CABG from the years 2009 to 2017. The outcomes included in-hospital, long-term mortality, and repeat revascularization. The follow-up was until death, end of Medicare AB coverage, or December 31, 2018. A total of 11,952 patients were identified. The mean age was 62.8 years, 68% were male, and 67% were white. The common co-morbidities included hypertension (97%), diabetes mellitus (75%), and congestive heart failure (53%). A significant decrease in CABG procedures from 2.9 to 1.3 procedures per 1,000 patients with ESKD (p <0.001) was noted during the years studied. The overall in-hospital mortality rate was 5.9%, and there was a significant decrease over the study period (p = 0.01). Although the 30-day mortality rate was 6.9% and remained steady (p = 0.14), the 1-year mortality rate was 22.8% and decreased significantly (p <0.001). At 5 years, the overall survival rate was 35%, and patients with internal mammary artery grafts showed better survival than those without (36% vs 25%). In conclusion, there has been a decrease in CABG procedures performed in patients with ESKD with stable CAD with decreasing in-hospital and 1-year mortality. Those with an internal mammary artery graft do better, but the overall long-term survival remains dismal in this population. There remains need for caution and individualization of revascularization decisions in this high-risk population., Competing Interests: Declaration of Competing Interest The authors have no competing interest to declare. The data reported here have been supplied by the United States Renal Data System. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Although the prognosis and management of severe aortic stenosis has been extensively studied, the risk stratification and outcomes of patients with moderate aortic stenosis remain elusive., Methods: This study included 674 patients from the Cleveland Clinic Health System with moderate aortic stenosis (aortic valve area, 1-1.5 cm 2 ; mean gradient, 20-40 mm Hg; and peak velocity <4 m/s) and an NT-proBNP (N-terminal pro-B-type natriuretic peptide) level within 3 months of index diagnosis. The primary outcome of major adverse cardiovascular events (defined as the composite outcome of progression to severe aortic stenosis requiring aortic valve replacement, heart failure hospitalization, or death) was extracted from the electronic medical record., Results: The mean age was 75.3±12 years, and 57% were men. During a median follow-up of 316 days, the composite end point occurred in 305 patients. There were 132 (19.6%) deaths, 144 (21.4%) heart failure hospitalizations, and 114 (16.9%) patients underwent aortic valve replacement. Elevated NT-proBNP (1.41 [95% CI, 1.01-1.95]; P =0.048), diabetes (1.46 [95% CI, 1.08-1.96]; P =0.01), elevated averaged mitral valve E/e' ratio (hazard ratio, 1.57 [95% CI, 1.18-2.10]; P <0.01), and presence atrial fibrillation at the time of index echocardiogram (hazard ratio, 1.83 [95% CI, 1.15-2.91]; P =0.01) were each independently associated with an increased hazard for the composite outcome and when taken collectively, each of these factors incrementally increased risk., Conclusions: These results further elucidate the relatively poor short-medium term outcomes and risk stratification of patients with moderate aortic stenosis, supporting randomized trials assessing the efficacy of transcatheter aortic valve replacement in this population., Competing Interests: Disclosures None.