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Purpose of Review The purpose of this review is to summarize the epidemiology, mechanisms, and management of cardiovascular complications of Bruton’s Tyrosine Kinase inhibitors (BTKIs). Recent Findings Ibrutinib increases the risk of atrial fibrillation, bleeding, and hypertension compared with non-BTKI therapies. The evidence to support an association between ibrutinib and other cardiovascular complications including ventricular tachyarrhythmias or cardiomyopathy is limited. Ibrutinib metabolism can be inhibited by some medications used to treat cardiovascular complications. The cardiovascular effects of more selective BTKIs, such as acalabrutinib, remain to be determined. Summary Future research should address the mechanisms underlying the cardiovascular complications of BTKIs and how best to manage them. The risks and benefits of more selective BTKIs as compared with ibrutinib require further evaluation.

BACKGROUND Proton pump inhibitor (PPI) antacid drugs have been shown to reduce the risk of gastrointestinal bleeding in patients taking antithrombotic medications and have been recommended for high risk patients since the publication of the 2008 ACCF/ACG/AHA consensus recommendations. We aimed to evaluate the rate of PPI use among outpatients receiving antithrombotic therapy at our tertiary care center. METHODS AND RESULTS We performed a retrospective study of cardiology outpatients between January 1st to February 28th, 2019, at an academic care centre. Among patients receiving antithrombotic therapy, we assessed the rate of documented PPI use. Patients were categorized according to the type of antithrombotic regimen as follows: single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), oral anticoagulation (OAC) therapy only, SAPT + OAC, or DAPT + OAC. Patients were stratified according to age 60 years or greater in a sub-analysis. Intergroup comparisons were performed using the chi-square test. A total of 2,503 unique patients were screened during the period of study, of whom 1,665 patients were documented to be receiving at least one antithrombotic agent. Of these, 548 (32.9%) were documented to be receiving PPI therapy (TABLE). The majority of patients were on antithrombotic monotherapy, with about half of patients (49.7%) receiving SAPT and another 35.1% receiving OAC alone. Only 9.8% of patients were receiving DAPT during the period of study and 5.4% were receiving both OAC and either SAPT or DAPT. The rate of PPI use was highest for the minority of patients receiving DAPT + OAC (100%) and those receiving DAPT (62.0%). Slightly under half of patients (45.0%) receiving SAPT + OAC were co-prescribed a PPI. Overall, a third or fewer (32.9%) patients receiving antithrombotic monotherapy were documented to be receiving a PPI. Age 60 years or more was associated with a roughly 50% increase in the rate of PPI co-prescription in the SAPT subgroup only (29% vs 17%, p CONCLUSION Gastrointestinal prophylaxis may be underutilized in cardiology outpatients. The finding that more patients with SAPT over the age of 60 are receiving PPI is in keeping with the 2008 ACCF/ACG/AHA consensus recommendations, but could also be explained by other factors, including weakened lower oesophageal sphincter function and multimorbidities. Additionally, it is important to identify other risk factors for gastrointestinal bleeding, such as prior history of peptic ulcer disease and concomitant steroid use. Targeted interventions to help clinicians recognize patients at risk of gastrointestinal bleeding could help optimize PPI prescription and avoid unnecessary morbidity.

Yafasova A, Butt JH, Elming MB, et al.

Background: The coronavirus disease-2019 (COVID-19) has profoundly disrupted health care services both by a massive influx of critical COVID-19 patients and through indirect effects, including medical care avoidance behaviors and the decreased efficiency of existing pathways of care Methods: We conducted a multinational retrospective survey analyzing the overall volume and the delays in presentation of acute coronary syndromes (ACS) and ischemic strokes during the COVID-19 pandemic (January 1, 2020, to April 30, 2020), comparing historical controls (same period in 2019) Eight centers in 4 countries contributed to the survey: Russia (4), Brazil (2), Kindgom of Saudia Arabia (1), and Tunisia (1) Results: While the ACS volume tended to increase in January and February 2020 in comparison to the same period in 2019, in March and April 2020 the number of ST-segment elevation myocardial infarction (STEMI) decreased by 17 6% and 39 2%, respectively, as well as the number of non-NSTEMI (by 9 6% and 26 4%, respectively) in comparison with March and April 2019 A gradual decrease in stroke cases along the first trimester was found (January -1 6%, February -3 1%, March -5 8%) when comparing 2020 to 2019, followed by 3 5% increase in April 2020 in comparison to March 2020 Early STEMI presentation (≤2 h) was less often encountered in the first quadrimester of 2020 in comparison with the first quadrimester of 2019 (36 2% vs 23 3%;p < 0 001) Conversely, the delays of ischemic strokes were similar between the 2 periods [Formula presented] Conclusion: The number of ACS patients requiring invasive approach decreased in March and April 2020 whereas no significant change in ischemic stroke volume was found along the first quadrimester of 2020 in comparison with the same period of 2019 Categories: CORONARY: Acute Coronary Syndromes

BACKGROUND The addition of low-dose rivaroxaban to aspirin in patients with stable atherosclerotic disease has been shown effective in reducing ischemic events. However, what proportion of cardiology patients might be deemed eligible for such therapy remains uncertain. We aimed to estimate the rate of eligibility among cardiology outpatients at an academic tertiary care center. METHODS AND RESULTS We retrospectively reviewed the antithrombotic treatment of all patients presenting to the cardiology clinic in an academic tertiary care center between January 1st to February 28th, 2019. Among patients with atherosclerotic disease, but without an indication for anticoagulation, we assessed the extent of atherosclerosis, recent ischemic events (myocardial infarction or cerebral vascular accident), ischemic risk factors (smoking, diabetes, dyslipidemia, history of stroke) and their eligibility for aspirin and low dose rivaroxaban combination therapy based on the inclusion criteria of the COMPASS trial. A total of 2503 unique patients consulted at the cardiology clinic during the period of study. Of these, 1172 patients (46.8%) had a diagnosis of atherosclerotic vascular disease, of whom 286 (24.4%) already received anticoagulation (TABLE). Among those without an indication for anticoagulation, 59 (6.7%) had no documented antithrombotic therapy, 616 (69.5%) patients were on ASA alone, and 46 (5.2%) were on P2Y12-inhibitor monotherapy. Of note, the coexistence of coronary and peripheral artery disease (often a criterion for formulary reimbursement) was documented in only 115 (13.0%) vascular disease patients without an indication for anticoagulation. CONCLUSION While a large proportion of cardiology outpatients could potentially benefit from the combination of ASA and low-dose rivaroxaban, the coexistence of coronary and peripheral vascular disease might be underdiagnosed. A combination of educational initiatives and targeted interventions might improve the identification of eligible patients and lead to better cardiovascular outcomes. Furthermore, given the bleeding risk associated with this drug combination, a shared decision making would also likely improve the quality of care.