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The prevalence of diabetes mellitus is increasing worldwide. Endothelial dysfunction plays a critical role in the pathophysiology of diabetes-related vascular complications. Several studies have shown that restoring blood glucose levels failed to reduce the incidence of major cardiovascular events in diabetic population, hence confirming the idea of “metabolic/hyperglycemic memory”. The major pathomechanism is, most likely, represented by the overproduction of reactive oxygen species (ROS). The purpose of this minireview is to summarize current knowledge about the mechanisms of metabolic memory and the impact of cardiovascular medication on this phenomenon, respectively.

BackgroundThe extent of medication-related harm in general practice is unknown.AimTo identify and describe all medication-related harm in electronic general practice records. The secondary aim was to investigate factors potentially associated with medication-related harm.Design and settingRetrospective cohort records review study in 44 randomly selected New Zealand general practices for the 3 years 2011–2013.MethodEight GPs reviewed 9076 randomly selected patient records. Medication-related harms were identified when the causal agent was prescribed in general practice. Harms were coded by type, preventability, and severity. The number and proportion of patients who experienced medication-related harm was calculated. Weighted logistic regression was used to identify factors associated with harm.ResultsIn total, 976 of 9076 patients (10.8%) experienced 1762 medication-related harms over 3 years. After weighting, the incidence rate of all medication-related harms was 73.9 harms per 1000 patient–years, and the incidence of preventable, or potentially preventable, medication-related harms was 15.6 per 1000 patient–years. Most harms were minor (n = 1385/1762, 78.6%), but around one in five harms were moderate or severe (n = 373/1762, 21.2%); three patients died. Eighteen study patients were hospitalised; after weighting this correlates to a hospitalisation rate of 1.1 per 1000 patient–years. Increased age, number of consultations, and number of medications were associated with increased risk of medication-related harm. Cardiovascular medications, antineoplastic and immunomodulatory agents, and anticoagulants caused most harm by frequency and severity.ConclusionMedication-related harm in general practice is common. This study adds to the evidence about the risk posed by medication in the real world. Findings can be used to inform decision making in general practice.

Introduction Cardiovascular disorders (CVS) belong to the most frequent causes of deaths and cardiovascular medications among the most common drugs. Older patients are vulnerable to drug risks due to presence of pharmacological changes, polymorbidity, polypharmacy and geriatric syndromes. Thus, the effort to reduce prescribing of potentially inappropriate medications (PIMs) represents a substantial prevention strategy in this population. Methods This was a prospective, cross-sectional study conducted in 288 patients (65+) admitted to acute care geriatric wards in the Czech Republic from Aug 2018 to Jan 2019. We aimed to investigate prevalence of CVS PIMs using relevant parts of STOPP/START 2015 criteria, the EU(7) PIM 2015 list and the Beers criteria 2019. Only patients with stable health conditions were included in our study. Results: Overall prevalence of CVS PIMs was 77.6%. Undertreatment of CVS problems, identified by START criteria, was found in 63.2% patients. Prevalence of CVS PIMs according to different criteria was 16.1%, 23.6% and 30.9%, using the Beers criteria 2012, STOPP criteria and the EU (7)-PIM list; respectively. The most prevalent problem of undertreatment was the absence of statins with documented history of coronary, cerebral and peripheral vascular disease (excluding patients at the end-of-life or at the age of >85 years) (27.3%). According to the EU (7)-PIM list, the most common CVS PIMs were the use of amiodarone in maintenance doses of >200 mg/48 hours and use of spironolactone in doses of >25 mg/day (9.0% and 5.6%; respectively). Conclusions This study confirmed high prevalence of CVS PIMs in older adults admitted to acute care hospitals in the Czech Republic. Detecting and identifying CVS PIMs is of high importance in order to prevent serious adverse drug events, higher mortality and increased frailty in vulnerable older population. Grant support: InoMed project (reg. No: CZ.02.1.01/0.0/0.0/18_069/0010046, 2019–2022), H2020-MCSF-ITN-764632, PROGRESS Q42 FoP, Charles University, SVV 260417.

BACKGROUND: Cash prices for prescription drugs vary among community pharmacies in the USA. GoodRx is a discount platform that provides coupons for use in community pharmacies without a membership requirement. Analytical pharmacy is a new type of pharmacy that tests drugs before dispensing to verify medication quality. OBJECTIVE: To compare undiscounted and GoodRx-discounted cash prices for common cardiovascular (CV) drugs by pharmacy type. DESIGN: A cross-sectional study. SETTING: GoodRx-discounted and GoodRx-undiscounted cash price data; analytical pharmacy cash price data (all data collected in July 2020). MEASUREMENTS: GoodRx cash price data for 30 units of 41 generic and 16 brand-name common cardiovascular medications at mass merchandiser, regional supermarket, two national chains, and analytical pharmacy (only one of its kind in the USA). RESULTS: The average (SD) undiscounted generic CV medication cash price was $42.41 (44.1). The average GoodRx-discounted generic CV medication cash prices were $11.01 (8.6), $9.88 (6.7), $17.85 (10.5), and $21.73 (14.1) in mass merchandiser, supermarket, and two national chain pharmacies, respectively. The average generic CV medication cash price was $20.84 (25.7) at the analytical pharmacy. The average (SD) undiscounted brand-name CV medication cash price was $368.33 (127.00). The average GoodRx-discounted brand-name CV medication cash prices were $269.16 (118.1), $258.84 (108.6), $270.28 (118.4), and $274.60 (122.50) for mass merchandiser, supermarket, and two national chain pharmacies, respectively. The average (SD) brand-name CV medication cash price was $365.12 (116.20) at the analytical pharmacy. CONCLUSIONS: GoodRx-discounted cash prices of generic CV medications were significantly lower than undiscounted cash prices at supermarket, mass merchandiser, and national chain pharmacies. Analytical pharmacy cash prices too were significantly lower than traditional pharmacy undiscounted cash prices. GoodRx-discounted prices for brand-name CV medications did not differ significantly from undiscounted cash prices and between pharmacy types.

Background: Ventricular fibrillation (VF) waveform analyses are considered a reliable proxy for OHCA characteristics in out-of-hospital cardiac arrest (OHCA), but patient characteristics such as cardiovascular medication use might also be associated with changes in VF waveform measures. Objectives: To assess associations between cardiovascular medication use and amplitude spectrum area (AMSA) of VF, while correcting for the presence of cardiovascular disease (CVD), CVD risk factors, and OHCA characteristics. Methods: We included 990 VF patients from an OHCA registry in the Netherlands, with available information on medical history and cardiovascular medication use. Associations between cardiovascular medication use and AMSA were tested in a multivariate linear regression model, adjusting for CVD, CVD risk factors, and OHCA characteristics. Model performance was shown using R-square and R-change. We also calculated whether medication use was associated with faster dissolution of AMSA to lower values with increasing time delay. Results: In the multivariate analysis, when corrected for CVD, CVD risk factors and OHCA characteristics, only potassium-sparing agents were associated with a lower AMSA when compared to patients using other cardiovascular medications (OR 0.46 [95% CI 0.100.81]; P < 0.012). The decrease in AMSA with increasing EMS-call-to-ECG delay was the same for patients with and without cardiovascular medication use (all P > 0.05). Only a small part of the variance in AMSA could be explained by medication use (R-square 0.003 0.026). Adding OHCA characteristics to the model resulted in the largest R square change (0.090.15). Conclusions: It is unlikely that there is a strong and clinically relevant independent pharmacologic effect of cardiovascular medication use on AMSA. In OHCA, AMSA might be used as patient management tool without considering cardiovascular medication use.: It is unlikely that there is a strong and clinically relevant independent pharmacologic effect of cardiovascular medication use on AMSA. In OHCA, AMSA might be used as patient management tool without considering cardiovascular medication use.

Aims This study aims to provide an overview on contemporary gender differences in the risk factor control of coronary heart disease (CHD) patients. Methods and results Analyses were based on the cross-sectional ESC (European Society of Cardiology) EORP (EurObservational Research Programme) EUROASPIRE V (European Survey of Cardiovascular Disease Prevention and Diabetes) survey including data on CHD patients across 27 European countries. Men and women between 18 and 80 years old, hospitalized for a first or recurrent coronary event were included in the study. Data were available for 8261 patients of which 25.8% women. Overall, women had a worse risk factor control compared with men. Whereas women were more likely to be non-smokers (79.3% vs. 87.2%; P 0.05). Moreover, a lower proportion of women reached low-density lipoprotein cholesterol (LDL-C) target levels (31.4% vs. 22.1%; P Conclusion The risk factor control of CHD women is substantial worse compared with men despite little gender differences in cardiovascular medication intake. Further actions are needed to increase the awareness of the worse risk factor control in female CHD patients.

Women and men are different. This may seem obvious, but cardiovascular research too often treats women and men as interchangeable. Due to this, there is a lack of sex-specific knowledge about optimal treatment for patients suffering from cardiovascular diseases such as heart failure. Sex differences in pharmacokinetics and – dynamics can affect how women react to cardiovascular medication compared with men, supporting the idea of sex-specific approaches to treatment. However, women remain underrepresented in clinical heart failure trials and thus data on safety and efficacy of heart failure medication in women is scarce. This thesis explores whether clinical care data can close this evidence gap. Clinical care data comprise electronic patient records, which better reflect the patient population seen in daily care than for example clinical trials. This means that women are properly represented in these data, creating opportunities for sex differences research. Using a large clinical care dataset, we show that women more often stop their cardiovascular medication due to adverse drug reactions than men. In addition, women report different adverse drug reactions than men for the same medication types. We also show that the optimal dosage of heart failure medication may be lower for women compared with men. Women treated with ≤50% of the guideline-recommended dose had a lower mortality risk than those treated with higher doses, an effect that was not seen in men. Lastly, we show that primary prevention statins reduce mortality risk more strongly in women than in men, taking away remaining doubts surrounding the effectiveness of statins in women free of cardiovascular disease. However, it remains debatable whether clinical care data alone are sufficient to completely close existing evidence gaps as these data have their own inherent limitations. The last chapter of this thesis discusses how these limitations can affect the quality of clinical care data-based research, and how researchers can mitigate these effects via statistical and methodological techniques. We conclude that clinical care data are and will remain an important source of information for sex differences research, as current and future efforts aimed at quality improvements will only reduce the size and effect of any inherent limitations that these data have.

Admission of certain medications (drugs) can cause the development of atrial fibrillation (AF) in patients having non-evident cardiovascular disease (CVD). Also, it can accelerate the onset of AF in patients with pre-existing CVD. It is important to realize medications as potential cause of AF, especially in elderly people, since aging is associated with comorbidity and use of many medications simultaneously, that can lead to higher incidence of druginduced AF (DI AF). The article provides literature review on medications used to treat CVD, the admission of which can lead to the development of DI AF. Its onset can be associated with the use of cardiotonic, antiarrhythmic and antianginal medications, calcium channel blockers, diuretics, antiplatelet agents and some others with different evidence levels. The frequency, mechanisms of DI AF development and methods for its correction are described.

Background: Australian data suggest that one-fifth of emergency department (ED) presentations are re-presentations within 28 days of discharge, with early re-presentations common. The contribution of medication misadventure to re-presentations has been poorly defined to date, but has been reported previously as medication-related readmission rates of 23%, of which 90% are considered preventable. Aims: This study identified and categorised medication-related 28-day ED re-presentations after discharge, associated medication-related problems (MRPs) and differences in demographics between medication-related and -unrelated ED re-presentations. Methods: A retrospective medical record review was conducted for every third adult 28-day ED re-presentation between 1 July and 31 December 2016. Re-presentations were examined for potential medication-related causes. The MRPs identified were categorised using causality, contribution and preventability criteria. Results: Of 631 eligible re-presentations, 196 were sampled. Re-presentations were potentially medication related in 41 (21%) cases; in 24 (59%) re-presentations, preventable MRPs were considered the main cause of re-presentation. Early medication-related re-presentations were common: 49% occurred within 7 days of discharge, and 20% on Day 1. Patients re-presenting with an MRP were, on average, 10.3 years older and prescribed 3.4 more medications on the index discharge than those re-presenting with a non-MRP. Cardiovascular medications (n = 14) were most commonly implicated in MRPs, with toxicity or adverse reaction (n = 16) and undertreated (n = 15) the most common MRP categories. Conclusions: One-fifth of the 28-day ED re-presentations observed were considered potentially medication related, with 59% of these associated with MRPs considered preventable. MRPs most frequently involved cardiovascular medications, adverse reactions and undertreatment. Early individualised pharmaceutical review after discharge may help reduce the MRPs observed.

Talea Cornelius,1 Corrine I Voils,2,3 Redeana C Umland,1 Ian M Kronish1 1Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; 2William S Middleton Veterans Memorial Hospital, Madison, WI 53705, USA; 3Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI 53792, USACorrespondence: Talea CorneliusCenter for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, 622 West 168th Street PH9-319, New York, NY 10032, USATel +1212-304-5215Email tmc2184@cumc.columbia.eduBackground: Self-report measures are important tools for assessing adherence to medication. Many of these scales, however, combine the extent of and reasons for nonadherence in one instrument, and have limited reliability and validity. The present study was the first to assess the convergent validity of the self-reported Domains of Subjective Extent of Nonadherence (DOSE-Nonadherence) scale with electronically measured adherence to a single cardiovascular medication.Methods: English- and Spanish-speaking patients evaluated for acute coronary syndrome (N=165; n=68 and n= 97, respectively) were recruited from an urban academic emergency department. Post-hospital discharge, participants were mailed a medication bottle with an electronic cap (eCAP) that recorded bottle openings. At 1 month, participants completed the 3-item DOSE-Nonadherence scale, which assessed the extent to which patients missed, skipped, or did not take the eCAP-monitored medication over the past 7 days. Correlations, sensitivity, and specificity were calculated using eCAP-monitored correct dosing adherence over the same 7-day time period as the reference standard.Results: The most commonly assessed medication was aspirin (70.91%). Correlations between self-reported and electronically monitored adherence were low-to-moderate: English-speaking participants (n=68), r=0.24, p=0.046; Spanish-speaking participants (n=97), r=0.18, p=0.071. Sensitivity was low (0.47 English, 0.28 Spanish) and specificity was moderate (0.77 English, 0.88 Spanish).Conclusions: The DOSE-Nonadherence scale was associated with electronically monitored adherence to a single daily cardiovascular medication in English-speaking participants, but had weak diagnostic properties when using electronic adherence as the reference standard.Keywords: medication adherence, self-report, nonadherence, validity, electronic monitoring

BackgroundCardiovascular medications have well-established benefits in the primary and secondary prevention of cardiovascular diseases. Unfortunately, adherence to these medicines is often suboptimal. To develop interventions intended to enhance adherence to cardiovascular medications, more insight

OBJECTIVE Liquid chromatography—tandem mass spectrometry (LC-MS/MS) is a new method to objectively and robustly detect nonadherence. We applied this technique to study nonadherence to cardiovascular medications in people with type 2 diabetes (T2DM). RESEARCH DESIGN AND METHODS Routine urine samples, received at the time of the annual diabetes review from 228 people with T2DM in primary care, were assessed for adherence by LC-MS/MS. RESULTS A total of 28.1% patients (N = 64) were nonadherent to antidiabetic, antihypertensive, and/or lipid-lowering medications. Nonadherence to statins was the highest at 23.7%, and nonadherence to oral hypoglycemic agents was 9.3%. HbA1c, albumin-to-creatinine ratio, and lipid profiles were significantly higher in the patients who were nonadherent compared with those who were adherent to treatment. CONCLUSIONS This unique study shows that routine urine samples can be used for adherence testing screening by LC-MS/MS and has demonstrated high nonadherence rates especially to statins in people with T2DM. Future intervention studies using LC-MS/MS as a diagnostic/therapeutic tool may help to improve clinical outcomes.

Objectives Associations between saliva volumes or salivary flow rates and potentially xerogenic medication are rarely evaluated in cohorts with a wide age range. This cross-sectional cohort study investigated possible relationships between the regular consumption of potentially xerogenic medication and stimulated saliva volumes. Methods Data from the German Studies of Health in Pomerania (SHIP-2 and SHIP-Trend-0) were pooled. Potentially xerogenic medications were identified using the Workshop on Oral Medicine VI criteria. Stimulated saliva was sampled using Salivette®, and saliva volumes expressed as μl/min were determined. Applying linear mixed models with adjustment for time point of saliva collection, associations of (a) age and sex with regularly consumed medication, (b) age and sex with saliva volumes, and (c) the number of regularly consumed xerogenic medications with saliva volumes were evaluated. Results Six thousand seven hundred and fifty-three participants aged 20-83 years (mean 53.4 ± 14.9) were included. The average number of medications did not differ markedly between females (2.21 ± 2.46) and males (2.24 ± 2.83). Males took more potentially xerogenic medication (1.0 ± 1.3) than did females (0.9 ± 1.3). Also, males took more potentially xerogenic cardiovascular medications than did females (0.9 ± 1.2 versus 0.7 ± 1.1), while females were prescribed a higher number of potentially xerogenic medications affecting the nervous system (0.2 ± 0.5 versus 0.1 ± 0.4). The average stimulated saliva volume was 967.0 ± 433.3 µL/min. Regularly consumed and potentially xerogenic medications were associated with lower saliva volumes. Older age correlated not only with a higher number of total medications and a higher number of xerogenic medications affecting either the cardiovascular (in males) or the nervous system (in females), but also with lower saliva volumes. Conclusions Ageing was associated with polypharmacy, especially with the intake of potentially xerogenic medication, and lower average saliva volumes. With regard to complications of dry mouth, anamnesis of medication consumption is of high importance.

OBJECTIVES: To describe long-term antithrombotic management patterns (AMPs) in medically managed Asian patients with non-ST-segment myocardial infarction (NSTEMI) or unstable angina (UA). BACKGROUND: Current guidelines support an early invasive strategy in NSTEMI and UA patients, but many are medically managed, and data are limited on long-term AMPs in Asia. METHODS: Data were analyzed from medically managed NSTEMI and UA patients included in the prospective, observational EPICOR Asia study (NCT01361386). Survivors to hospital discharge were enrolled (June 2011 to May 2012) from 8 countries/regions across Asia. Baseline characteristics and AMP use up to 2 years post-discharge were collected. Outcomes were major adverse cardiovascular events (MACE: myocardial infarction, ischemic stroke, and death) and bleeding. RESULTS: Among 2289 medically managed patients, dual antiplatelet therapy (DAPT) use at discharge was greater in NSTEMI than in UA patients (81.8% vs 65.3%), and was significantly associated with male sex, positive cardiac markers, and prior cardiovascular medications (p

International audience; Aims: Acute heart failure (AHF) is frequent and life-threatening disease. However, innovative AHF therapies have remained limited, and care is based on experts opinion. Temporal trends and benefits of long-term oral cardiovascular medications on AHF outcomes remain uncertain.Methods and results: This study is registered with PROSPERO (CRD42018099885). A systematic review ranging from 1980 to 2017, searched AHF studies with more than 100 patients that reported death and/or readmission. Primary outcomes were temporal trends, assessed by meta-regression, for 30-day or one-year all-cause death and/or readmission rates. Secondary outcomes were temporal trends of oral cardiovascular therapies and their influence on primary outcomes. Among the 45143 studies screened, 285 were included, representing 15 million AHFs. In the past decades, though mortality and readmission remain high, there was a decline in 30-day all-cause death (OR for a 10-year increment: 0.74 (0.61-0.91); p=0.004) that persisted at one year (OR 0.86 (0.77- 0.96); p=0.007), while 30-day and one-year all-cause readmission rate remained roughly unchanged. Trends of primary outcomes were linear and did not differ among continents. Decline in one-year all-cause death rate correlated with high proportions of oral or beta-blockers, especially when combined with oral renin-angiotensin-aldosterone system inhibitors, but not with diuretics while trends in readmission remained unchanged with these therapies.Conclusions: Though AHF outcomes remain poor, the present study revealed global favorable trends of survival after AHF episodes probably associated with greater use of oral neurohormonal antagonists. The present study urges to implement the combination of oral renin-angiotensin-aldosterone system inhibitors and beta-blockers in patients at risk of AHF. This article is protected by copyright. All rights reserved.

Background There is no clinical guidance on treatment in patients with non‐ischemic myocardial injury and type 2 myocardial infarction (T2MI). Methods and Results In a cohort of 22 589 patients in the emergency department at Karolinska University Hospital in Sweden during 2011 to 2014 we identified 3853 patients who were categorized into either type 1 myocardial infarction, T2MI, non‐ischemic acute and chronic myocardial injury. Data from all dispensed prescriptions within 180 days of the visit to the emergency department were obtained concerning β‐blockers, angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers, statins, and platelet inhibitors. We estimated adjusted hazard ratios (HR) with 95% CI for all‐cause mortality in relationship to the number of medications (categorized into 0–1 [referent], 2–3 and 4 medications) in the groups of myocardial injury. In patients with T2MI, treatment with 2 to 3 and 4 medications was associated with a 50% and 56% lower mortality, respectively (adjusted HR [95% CI], 0.50 [0.25–1.01], and 0.43 [0.19–0.96]), while corresponding associations in patients with acute myocardial injury were 24% and 29%, respectively (adjusted HR [95% CI], 0.76 [0.59–0.99] and 0.71 [0.5–1.02]), and in patients with chronic myocardial injury 27% and 37%, respectively (adjusted HR [95% CI], 0.73 [0.58–0.92] and 0.63 [0.46–0.87]). Conclusions Patients with T2MI and non‐ischemic acute or chronic myocardial injury are infrequently prescribed common cardiovascular medications compared with patients with type 1 myocardial infarction. However, treatment with guideline recommended drugs in patients with T2MI and acute or chronic myocardial injury is associated with a lower risk of death after adjustment for confounders.

The liver-heart axis is a growing field of interest owing to rising evidence of complex bidirectional interplay between the two organs. Recent data suggest non-alcoholic fatty liver disease (NAFLD) has a significant, independent association with a wide spectrum of structural and functional cardiac diseases, and seems to worsen cardiovascular disease (CVD) prognosis. Conversely, the effect of cardiac disease on NAFLD is not well studied and data are mostly limited to cardiogenic liver disease. We believe it is important to further investigate the heart-liver relationship because of the tremendous global health and economic burden the two diseases pose, and the impact of such investigations on clinical decision making and management guidelines for both diseases. In this review, we summarize the current knowledge on NAFLD diagnosis, its systemic manifestations, and associations with CVD. More specifically, we review the pathophysiological mechanisms that govern the interplay between NAFLD and CVD and evaluate the relationship between different CVD treatments and NAFLD progression.

Cardiovasculardisorders(CVS)belongtothemostfrequentcausesofdeaths,andcardiovascularmedicationsamongthemostcommondrugs.Olderpatientsarevulnerabletodrugrisksduetopharmacologicalchanges,polymorbidity,polypharmacyandgeriatricsyndromes.Thus,theefforttoreduceprescribingofpotentiallyinappropriatemedications(PIMs)representsasubstantialpreventionstrategyinthispopulation.

Introduction: Amiodarone and diltiazem are commonly prescribed cardiovascular medications in atrial fibrillation (AF) patients who take direct oral anticoagulants (DOACs). They are known to have drug-drug interactions (DDIs) with DOACs, increasing serum levels of DOACs by 40-60%, and potentially increasing risk of bleeding. Objective: To evaluate frequency of use of amiodarone or diltiazem among continuous users of DOACs in AF patients and assess factors associated with their use. Methods: The study population included all AF patients with continuous DOAC use in Ontario, Canada, ≥66 years, from April 1 2017 to March 31 2018. We used linked databases housed at ICES, Ontario. DOAC fill dates and days supplied per prescription were used to determine treatment durations. A maximum gap of 30 days between prescriptions was allowed. Multivariable logistic regression models were used to identify predictors of prescribing amiodarone or diltiazem among AF patients on DOACs. Results: In total, 5390 AF patients, ≥66 years, with continuous DOAC use were identified. Amiodarone was co-prescribed in 343 (6.4%) patients and diltiazem was co-prescribed in 604 (11.2%) patients. The presence of percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) significantly increased the odds of co-prescribing amiodarone among AF DOAC patients (OR 2.52 [95% CI 1.55, 4.10], p=0.0002 and OR 5.19 [95% CI 3.46, 7.80], p= Conclusions: Among AF patients with continuous DOAC use, the presence of PCI or CABG was associated with increased amiodarone co-prescription. Future efforts should focus on examining the risk of bleeding in these vulnerable populations exposed to major DOAC DDIs.

The cardiologist is frequently called upon to assist in the management of patients with cardiovascular disease in the perioperative setting. Questions surrounding risk stratification and management, appropriate diagnostic testing, management of cardiovascular medications, and coronary revascularization, among others, are germane to the optimal management of such patients. In general, the approach to management, and indications for diagnostics and therapies, are the same as if the patient were not proceeding to surgery. The cardiovascular consultant must be prepared to approach this scenario and its questions in a systematic and evidence-based fashion.

In the ongoing coronavirus diseases-2019 (COVID-19) crisis that caused immense suffering and deaths, the choice of therapy for the prevention and life-saving conditions must be based on sound scientific evidence. Uncertainty and apprehension are exacerbated in people using angiotensin-converting enzyme (ACE) inhibitors to control their comorbidities such as hypertension and diabetes. These drugs are reported to result in unfavorable outcome as they tend to increase the levels of ACE2 which mediates the entry of SARS-CoV-2. Amiloride, a prototypic inhibitor of epithelial sodium channels (ENaC) can be an ideal candidate for COVID-19 patients, given its ACE reducing and cytosolic pH increasing effects. Moreover, its potassium-sparing and anti-epileptic activities make it a promising alternative or a combinatorial agent.

Background Medication harm can lead to hospital admission, prolonged hospital stay and poor patient outcomes. Reducing medication harm is a priority for healthcare organisations worldwide. Recent Australian studies demonstrate cardiovascular (CV) medications are a leading cause of harm. However, they appear to receive less recognition as ‘high risk’ medications compared with those classified by the medication safety acronym, ‘APINCH’ (antimicrobials, potassium, insulin, narcotics, chemotherapeutics, heparin). Our aim was to determine the scale and type of medication harm caused by CV medications in healthcare. Methods A narrative review of adult (>16 years) medication harm literature identified from PubMed and CINAHL databases was undertaken. Studies with the primary outcome of measuring the incidence of medication harm were included. Harm caused by CV medications was described and ranked against other medication classes at four key stages of a patient’s healthcare journey. Where specified, the implicated medications and type of harm were investigated. Results A total of 75 studies were identified, including seven systematic reviews and three meta-analyses, with most focussing on harm causing hospital admission. CV medications were responsible for approximately 20% of medication harm; however, this proportion increased to 50% in older populations. CV medications were consistently ranked in the top five medication categories causing harm and were often listed as the leading cause. Conclusion CV medications are a leading cause of medication harm, particularly in older adults, and should be the focus of harm mitigation strategies. A practical approach to generate awareness among health professionals is to incorporate ‘C’ (for CV medications) into the ‘APINCH’ acronym. Plain language summary Patient harm from cardiovascular medications Background • Harm from medications can cause poor patient outcomes. • Certain medications have been identified as ‘high risk’ and are known to cause high rates of harm. • ‘High risk’ medications are included in medication guidelines used by health professionals. • Cardiovascular medications (e.g. blood pressure and cholesterol medications) are important and have many benefits. • Recent studies have found cardiovascular medications to cause high rates of harm. • Cardiovascular medication harm is often under-recognised in clinical practice. • Some guidelines do not consider cardiovascular medications to be ‘high risk’. Method • This review investigated the extent of harm caused by cardiovascular medications in adults across four healthcare settings: (1) at the time of hospital admission; (2) during hospital admission; (3) after hospital; and (4) readmission to hospital. • Harm caused by cardiovascular medications was ranked against other medication classes. • We investigated the type of cardiovascular medications to cause harm and the type of harm caused. Results • Seventy-five studies were reviewed across 41 countries. • Cardiovascular medications were ranked within the top five medications to cause harm. • Cardiovascular medications were a leading cause of harm in each healthcare setting investigated. • Harm caused by cardiovascular medications was common in older adults (>65 years). • Cardiovascular medications often caused preventable harm. • Medications to treat high blood pressure and abnormal heart rhythms were the most common causes of harm. • We reported kidney injury, electrolyte changes and low blood pressure as common types of harm. Conclusion • Increased focus on cardiovascular medications in clinical practice is needed. • Health professionals need to carefully prescribe and frequently review cardiovascular medications, especially in older adults. • Patient and health professional discussions should be based on both the benefits and harms of cardiovascular medications. • Cardiovascular medications should be included in all ‘high risk’ medication guidelines.

Background To manage the risk factors and to improve clinical outcomes, patients with stroke commonly receive multiple cardiovascular medications. However, there is a lack of evidence on the optimum combination of medication therapy in the primary care setting after ischemic stroke. Therefore, this study aimed to investigate the effect of multiple cardiovascular medications on long-term survival after an incident stroke event (ischemic stroke or transient ischemic attack (TIA)). Methods This study consisted of 52,619 patients aged 45 and above with an incident stroke event between 2007 and 2016 in The Health Improvement Network database. We estimated the risk of all-cause mortality in patients with multiple cardiovascular medications versus monotherapy using a marginal structural model. Results During an average follow-up of 3.6 years, there were 9230 deaths (7635 in multiple cardiovascular medication groups and 1595 in the monotherapy group). Compared with patients prescribed monotherapy only, the HRs of mortality were 0.82 (95% CI 0.75–0.89) for two medications, 0.65 (0.59–0.70) for three medications, 0.61 (0.56–0.67) for four medications, 0.60 (0.54–0.66) for five medications and 0.66 (0.59–0.74) for ≥ six medications. Patients with any four classes of antiplatelet agents (APAs), lipid-regulating medications (LRMs), angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta-blockers, diuretics and calcium channel blockers (CCBs) had the lowest risk of mortality (HR 0.51, 95% CI 0.46–0.57) versus any one class. The combination containing APAs, LRMs, ACEIs/ARBs and CCBs was associated with a 61% (95% CI 53–68%) lower risk of mortality compared with APAs alone. Conclusion Our results suggested that combination therapy of four or five cardiovascular medications may be optimal to improve long-term survival after incident ischemic stroke or TIA. APAs, LRMs, ACEIs/ARBs and CCBs were the optimal constituents of combination therapy in the present study.

BACKGROUND We aimed to investigate the association between cardiovascular medications prescribed at ICU discharge and 1-year mortality in intensive care unit (ICU) survivors. METHODS This retrospective observational study was conducted at a single tertiary academic hospital. The study population comprised adult patients (aged ≥18 years) who were admitted to the general ICU between January 2012 and December 2016, survived, and were discharged. "Cardiovascular medication of ICU survivors" was defined as cardiovascular medications prescribed to ICU survivors for continued use after ICU discharge. Patients who had any cardiovascular medication prescribed at ICU discharge were classified as the CV MED group (n=10,777); all other patients comprised the non-CV MED group (n=7,288). RESULTS A total of 18,065 ICU survivors participated in this study. After propensity score (PS) matching, a total of 8,456 patients (4,228 patients per group) were included in the analysis. In a Cox regression model, overall 1-year mortality after ICU discharge was 25% lower in the CV MED group, compared to the non-CV MED group (HR: 0.75, 95% CI: 0.66 to 0.84; P