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Aortic stenosis (AS) and acute coronary syndrome (ACS) share similar cardiovascular risk factors. The incidence of concomitant AS and ACS is increasing with aging population, yet studies investigating the prognosis of these patients remain scarce.This retrospective single-centre cohort study examined consecutive patients who presented with ACS and AS from January 1, 2011, to March 31, 2021. The cohort was divided into mild, moderate, and severe AS based on the index echocardiogram. The primary outcome was all-cause mortality.Of 563 patients, 264 (46.9%) had mild, 193 (34.3%) moderate, and 106 (18.8%) severe AS. The mean follow-up duration was 2.5 years. All-cause mortality was higher among patients with moderate and severe AS compared with mild AS within 30 days (17.0% vs 13.0% vs 6.4%, respectively; P = 0.005) and in the long term (49.7% vs 51.4% vs 35.6%; P = 0.002). Concomitant moderate (hazard ratio [HR] 1.453, 95% confidence interval [CI] 1.020-2.068; P = 0.038) or severe AS (HR 1.873, 95% CI 1.176-2.982; P = 0.008) was an independent predictor of all-cause mortality. Kaplan-Meier curves demonstrated higher mortality in patients with moderate and severe AS compared with mild AS (P0.001). Similar survival trends were observed regardless of ACS type and in those with preserved left ventricular ejection fraction. Patients with reduced left ventricular ejection fraction had poor prognosis regardless of AS severity.ACS patients with concomitant moderate or severe AS have similar high long-term mortality, regardless of ACS type. The high early mortality in moderate and severe AS emphasises the imperative to attempt to mitigate this risk urgently.

Literature of patients with severe high-gradient aortic stenosis (HG AS) (mean pressure gradient [MPG] ≥ 40 mmHg and aortic valve area [AVA] ≥ 1.0 cm

(1) Background: Treatment of dyslipidemia via statin therapy in the non-liver transplant (LT) population is associated with a mortality benefit; however, the impact of statin therapy in post-LT population is not well-defined. This meta-analysis seeks to investigate the safety and efficacy of statin therapy in post-LT patients. (2) Methods: A systematic literature search on Medline and EMBASE database was conducted. A single-arm proportional meta-analysis and conventional pair-wise meta-analysis were performed to compare different outcomes with a random effects model. (3) Results: A total of 11 studies were included in this study, with 697 LT recipients identified to be on statin therapy. Statins were underutilized with only 32% (95% CI: 0.15–0.52) of 1094 post-LT patients on therapy. The incidence of adverse events of 14% (95% CI: 0.05–0.25) related to statin therapy was low. A significant mortality benefit was noted in patients on statin therapy with HR = 0.282 (95% CI: 0.154–0.517, p < 0.001), and improved lipid profiles post LT. The use of statins also significantly decreased odds of graft rejection (OR = 0.33; 95% CI: 0.15–0.73) and hepatocellular carcinoma (HCC) recurrence (HR = 0.32, 95% CI: 0.11–0.89). (4) Conclusions: Statin therapy is safe and efficacious in post-LT patients. Future studies to evaluate the effects of interactions between statins and immunosuppressant therapy are warranted.

Aim To investigate the efficacy of bisphosphonates and compare oral and IV formulations on bone mineral density (BMD) and fracture incidence in post-orthotopic liver transplant (OLT) patients. Methods Electronic databases were searched, and six RCTs and three cohort studies were included out of 711 articles. Main outcomes included post-OLT BMD changes, fracture incidence, and treatment adverse reactions. Pairwise meta-analysis was conducted for binary and continuous outcomes, while pooled fracture incidence utilized single-arm meta-analysis. Results Post-OLT fracture incidence was reported in nine studies (n=591). Total fracture incidence was 6.6% (CI: 3.4% to 12.4%) in bisphosphonate group and 19.1% (CI: 14.3% to 25.1%) in calcium and vitamin D group. Total fractures were significantly lower in patients on bisphosphonate, compared to calcium and vitamin D (n = 591; OR = 0.037; CI: 0.18 to 0.77; p=0.008) Overall fractures were significantly lower in the oral group (n= 263; OR = 0.26; CI: 0.08 to 0.85, p=0.02) but not in the IV group (n = 328; OR = 0.45; CI: 0.16 to 1.26, p=0.129). Conclusion Both oral and IV bisphosphonates are effective in reducing fracture incidence post-OLT compared to calcium and vitamin D. Oral formulations may also have an advantage over IV in reducing bone loss and fracture incidence post-OLT.

IMPORTANCEThere are growing concerns that patients suffering from acute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors (SMuRFs), including hypertension, hypercholesterolemia, diabetes and smoking, have increased mortality.OBJECTIVEThis study examined the outcomes of ACS in patients without SMuRFs (termed SMuRF-less) in a multi-ethnic Asian population which remains unknown.DESIGNThis retrospective study was conducted from 1st January 2011 to 31st March 2021.SETTINGThis study was conducted in a tertiary healthcare institution in Singapore.PARTICIPANTSConsecutive patients presenting with ACS disease were recruited in the study.EXPOSUREThe outcomes of SMuRF-less patients were compared with SMuRF patients.MAIN OUTCOMES AND MEASURESThe primary outcome was cardiovascular mortality. Secondary outcomes were all-cause mortality, readmission, cardiogenic shock, stroke and heart failure. Multivariable regression analysis adjusted for covariates including age, sex, ethnicity, chronic kidney disease, ACS type, cardiac arrest, and left main and/or left anterior descending coronaryRESULTSOf the 8680 patients studied, 8.6% were SMuRF-less patients. SMuRF-less patients were significantly younger and had fewer comorbidities including stroke and chronic kidney disease, but higher rates of ventricular arrhythmias and inotropic or invasive ventilation requirement compared to the SMuRF group. Multivariable analysis showed higher rates of cardiovascular mortality (HR 1.48, 95% CI 1.09–1.86, p=0.048), cardiogenic shock (RR: 1.31, 95% CI 1.09–1.52, p=0.015) and stroke (RR: 2.51, 95% CI 1.67–3.34, p=0.030) in SMuRF-less patients compared to SMuRF patients. Both groups had similar readmission (RR: 1.10, 95% CI 0.87–1.39, p=0.413) and heart failure (RR: 0.82, 95% CI 0.56–1.21, p=0.326) rates. Kaplan-Meier curve showed higher 30-day cardiovascular mortality in the SMuRF-less group compared to SMuRF group (HR: 1.84, 95% CI 1.45-2.33, pCONCLUSION AND RELEVANCEAlthough the proportion of ACS patients without standard risk factors in our Asian population is lower than those reported in the West, they also have worse short-term mortality compared to those with SMuRF. This calls for a global focus on the management of this unexpectedly high-risk subgroup of patients.

Studies on the impact of aortic valve anatomy (bicuspid aortic valve [BAV] or tricuspid aortic valve [TAV]) on the progression of moderate aortic stenosis (AS) and ascending aorta (AA) dilatation and its prognostic implications are limited. From 1991 to 2016, 288 asymptomatic patients with moderate AS detected during index echocardiography with at least 1 year of echocardiographic follow-up were retrospectively studied. Baseline clinical and echocardiographic characteristics were compared between patients with BAV (n = 80) and patients with TAV (n = 208). Co-primary outcomes were 1-year hemodynamic and anatomic progression of AS and AA dilatation. Secondary end points were the incidence of AA rapid progressors, all-cause mortality, aortic valve replacement, and congestive heart failure. Determinants of AS progression, AA diameters, AA dilatation, and prognostic outcomes were evaluated. Similar 1-year progression of the aortic valve peak velocity, Vmax (9 ± 18 vs 9 ± 23 cm/s), mean gradient (1.5 ± 2.3 vs 1.3 ± 3.2 mm Hg), and aortic valve area (AVA) (−0.04 ± 0.09 vs −0.05 ± 0.10 cm2) were noted for BAV and TAV groups, respectively. One-year progressions of AA were similar at Valsalva (0.11 ± 0.88 vs 0.14 ± 1.10 mm) and tubular levels (0.12 ± 0.68 vs 0.30 ± 1.51 mm) in BAV and TAV groups, respectively. A trend toward increased rapid AA progression in patients with BAV (31.3%) was observed compared with patients with TAV (14.8%, p = 0.099). BAV was associated with progression of Vmax (β = 0.17, p = 0.036), the dimensionless index (β = −0.17, p = 0.008), and AVA (β = −0.14, p = 0.048), but not mean gradient after adjusting for age, baseline severity indexes, gender, hypertension, diabetes, and body surface area. Although BAV was a determinant of larger baseline AA diameter, there was no significant association between BAV and AA rapid progressors. Adjusted Kaplan-Meier curves demonstrated no differences in congestive heart failure, aortic valve replacement, or mortality between valve morphology. In conclusion, there was a similar 1-year disease progression in terms of AVA, Vmax, mean gradient, and AA diameters between patients with BAV and patients with TAV. BAV was associated with a significant increase in Vmax, dimensionless index, and AVA after adjusting for important confounders. Close and prolonged follow-up is warranted in both groups of patients.