Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease

Prognostic Value of Cardiac MRI Late Gadolinium Enhancement Granularity in Participants with Ischemic Cardiomyopathy

Background Ischemic late gadolinium enhancement (LGE) assessed with cardiac MRI is a well-established prognosticator in ischemic cardiomyopathy. However, the prognostic value of additional LGE parameters, such as extent, transmurality, location, and associated midwall LGE, remains unclear. Purpose To assess the prognostic value of ischemic LGE features to predict all-cause mortality in ischemic cardiomyopathy. Materials and Methods This study is a secondary analysis of a prospective dual-center trial of participants with ischemic cardiomyopathy and left ventricular ejection fraction (LVEF) under 50% referred for viability assessment using cardiac MRI between 2008 and 2022. The LGE granularity parameters (extent of ischemic LGE, transmurality, location, and associated midwall LGE) assessed by cardiac MRI experts were compared with traditional prognosticators of adverse events in ischemic cardiomyopathy (age, sex, body mass index, diabetes, smoking, dyslipidemia, heart failure hospitalization, atrial fibrillation, renal failure, known myocardial infarction, and LVEF). The primary outcome was all-cause mortality. Predictive value was evaluated using Cox regression analysis and assessed using time-dependent receiver operating characteristic curves at 10 years. The cardiac MRI LGE score was developed using LGE granularity parameters. Results Among 6082 participants (mean age, 64.5 years ± 11.8 [SD]; 4419 men), 3591 had ischemic LGE. During a median follow-up of 9.0 years (IQR, 6.6-11.5 years), 652 participants died. The presence of ischemic LGE was strongly associated with mortality (hazard ratio, 3.45 [99.5% CI: 2.55, 4.67]; P < .001). In the group with ischemic LGE, the LGE granularity model combining these LGE features showed the best predictive value above traditional prognosticators and ischemic LGE extent to predict all-cause mortality (area under the receiving operating characteristic curve [AUC] at 10 years, 0.89 [99.5% CI: 0.89, 0.90] vs 0.83 [99.5% CI: 0.83, 0.84]; P < .001). The cardiac MRI LGE score performed well in participants with ischemic LGE (AUC at 10 years, 0.87 [99.5% CI: 0.85, 0.90]). Conclusion In a large cohort of participants with ischemic cardiomyopathy, an LGE granularity model had a higher prognostic value over traditional prognosticators to predict mortality. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Lima and Ebrahimihoor in this issue.

Peripheral artery disease in patients with stable coronary artery disease in general practice: results from an Italian nationwide study-PAD & CAD study

Peripheral artery disease (PAD) remains underdiagnosed in patients with coronary artery disease (CAD) and barriers persist to measure screening PAD in routine clinical practice. We assessed the prevalence of PAD in patients with CAD in Italian primary care setting using an easy automatic instrument to measure ankle brachial pressure index (ABI). A multicenter, observational study was conducted with 32 General Practitioners (GPs). Prevalence of PAD was calculated dividing the number of patients with abnormal ABI value, or with symptoms associated with PAD or history of lower limb revascularization procedures, over the total number of patients included in the study. Incidence of major CV clinical events and all-cause death was also evaluated at 12 months in both CAD and CAD + PAD groups. In total, 713 CAD patients were included in the study, 148 (20.8%) patients had also PAD, asymptomatic in nearly 15% of them (106). The 35.4% of patients had ABI value ≤ 0.9 and 46.0% > 1.3 ABI. A significantly higher incidence of major CV events and all-cause death was seen in patients with PAD than in those without. Over 80% of patients received the therapy for secondary CV prevention and difference was seen between groups. Our findings showed that the use of an easy automatic instrument to measure ABI, easily managed by nurses, allowed to detect PAD in a relevant proportion of CAD patients who otherwise would not have been recognized. This encourages performing PAD screening in primary care setting to optimize the management of major CV risk factors associated with PAD. NCTumber: NCT03921905.

Rethinking atherosclerotic cardiovascular disease prevention in the era of expanding therapies: could plaque stabilization reduce the need for lifelong treatments and polypharmacy?

PURPOSE OF REVIEW

This review examines current evidence on pharmacologically induced plaque stabilization in the context of a growing range of new therapies. It explores the potential for a paradigm shift in atherosclerotic cardiovascular disease (ASCVD) prevention, where treatments may not need to be lifelong to achieve lasting benefits.

RECENT FINDINGS

Since 2015, over 14 novel therapies have been introduced, each shown to reduce ASCVD risk when added to standard care with statins and aspirin. More than 80% of ischemic heart disease patients are now eligible for one or more of these treatments, increasing the risk of polypharmacy, treatment burden, and adverse side effects. As more therapies become available, this challenge is expected to grow. Many of these treatments have demonstrated plaque regression and stabilization, as evidenced by both intravascular ultrasound and computed tomography angiography, which likely explains much of their efficacy.

SUMMARY

The increasing number of novel therapies presents challenges in preventing ASCVD without leading to lifelong polypharmacy and increased patient burden. Since many of these drugs act through plaque stabilization, a new approach may be feasible - using these treatments for shorter durations to induce plaque regression, followed by less intensive maintenance therapies to preserve stability. This approach warrants further investigation in future studies.

Unravelling the cardio-renal-metabolic-foot connection in people with diabetes-related foot ulceration: a narrative review

Diabetes-related foot ulceration (DFU), a serious but preventable complication of diabetes, is a leading cause of hospitalisation, lower extremity amputation and disability worldwide. People with DFU have a greater burden of cardiovascular risk factors, heart failure and chronic kidney disease, resulting in over two-fold higher risk of cardiovascular death compared with people with diabetes without DFU. Here, we propose a "cardio-renal-metabolic-foot" connection in people with diabetes based on shared pathophysiological mechanisms linking DFU with cardiovascular and renal disease. Whilst these mechanistic links remain to be fully elucidated, systemic inflammation and infection in the context of DFU are postulated as key mediators in the development, and progression of, cardiovascular and renal disease. However, cardiovascular and renal disease are also implicated in the pathogenesis of DFU, highlighting the multi-directional interplay between conditions. The impact of screening, prevention, and early management of cardiovascular complications associated with DFU requires further research. Multi-modality cardiac imaging could play a role in unravelling disease mechanisms leading to novel therapeutic strategies, as well as facilitating personalised risk assessment and management. Recent clinical trials have transformed the therapeutic landscape for people with type 2 diabetes, by demonstrating that sodium glucose co-transporter 2 inhibitors, glucagon-like peptide-1 agonists and non-steroidal mineralocorticoid receptor antagonists improve cardiovascular and renal outcomes. Although dedicated research in people with DFU is warranted, these therapies could target multiple facets of the "cardio-renal-metabolic-foot" connection. The holistic, person-centred approach to managing DFU should incorporate new multidisciplinary models of care focusing on the prevention and management of cardiovascular and kidney disease.

Identification and Evaluation of Angiogenesis-Related Proteins That Predict Major Adverse Cardiovascular Events in Patients with Peripheral Artery Disease

BACKGROUND

The most common cause of death in patients with peripheral artery disease (PAD) are major adverse cardiovascular events (MACEs), including myocardial infarction (MI) and stroke. However, data on biomarkers that could be used to help predict MACEs in patients with PAD to guide clinical decision making is limited. Angiogenesis-related proteins have been demonstrated to play an important role in systemic atherosclerosis and may act as prognostic biomarkers for MACEs in patients with PAD. In this study, we evaluated a large panel of angiogenesis-related proteins and identified specific biomarkers associated with MACEs in patients with PAD.

METHODS

We conducted a prognostic study using a prospectively recruited cohort of 406 patients (254 with PAD and 152 without PAD). Plasma concentrations of 22 circulating angiogenesis-related proteins were measured at baseline, and the cohort was followed for 2 years. The primary outcome was 2-year MACEs (composite of MI, stroke, or death). Plasma protein concentrations were compared between PAD patients with and without 2-year MACEs using Mann-Whitney U tests. Differentially expressed proteins were further investigated in terms of their prognostic potential. Specifically, Cox proportional hazards analysis was performed to determine the independent association between differentially expressed proteins and 2-year MACEs, controlling for all baseline demographic and clinical characteristics, including existing coronary artery disease and cerebrovascular disease. Kaplan-Meier analysis was conducted to assess 2-year freedom from MACEs in patients with low vs. high levels of the differentially expressed proteins based on median plasma concentrations.

RESULTS

The mean age of the cohort was 68.8 (SD 11.1), and 134 (33%) patients were female. Two-year MACEs occurred in 63 (16%) individuals. The following proteins were significantly elevated in PAD patients with 2-year MACEs compared to those without 2-year MACEs: endostatin (69.15 [SD 58.15] vs. 51.34 [SD 29.07] pg/mL, p < 0.001), angiopoietin-like protein 4 (ANGPTL4) (0.20 [SD 0.09] vs. 0.12 [SD 0.04] pg/mL, p < 0.001), and ANGPTL3 (51.57 [SD 21.92] vs. 45.16 [SD 21.90] pg/mL, p = 0.001). Cox proportional hazards analysis demonstrated that these three proteins were independently associated with 2-year MACEs after adjusting for all baseline demographic and clinical characteristics: endostatin (HR 1.39 [95% CI 1.12-1.71] p < 0.001), ANGPTL4 (HR 1.35 [95% CI 1.08-1.68], p < 0.001), and ANGPTL3 (HR 1.35 [95% CI 1.12-1.63], p < 0.001). Over a 2-year follow-up period, patients with higher levels of endostatin, ANGPTL4, and ANGPTL3 had a lower freedom from MACEs. Supplementary analysis demonstrated that these three proteins were not significantly associated with 2-year MACEs in patients without PAD.

CONCLUSIONS

Among a panel of 22 angiogenesis-related proteins, endostatin, ANGPTL4, and ANGPTL3 were identified to be independently and specifically associated with 2-year MACEs in patients with PAD. Measurement of plasma concentrations of these proteins can support MACE risk stratification in patients with PAD, thereby informing clinical decisions on multidisciplinary referrals to cardiologists, neurologists, and vascular medicine specialists and guiding aggressiveness of medical treatment, thereby improving cardiovascular outcomes in patients with PAD.

Prediction of Major Adverse Cardiovascular Events in Patients with Peripheral Artery Disease Using Circulating Immunomodulatory Proteins

Background/Objectives: The leading cause of death for people with peripheral artery disease (PAD) is major adverse cardiovascular events (MACE), including heart attacks and strokes. However, research into biomarkers that could help predict MACE in patients with PAD has been limited. Immunomodulatory proteins are known to significantly influence systemic atherosclerosis, suggesting they could be useful prognostic indicators for MACE in patients with PAD. In this study, we evaluated a broad panel of immunomodulatory proteins to identify those linked to MACE in individuals with PAD. Methods: We conducted a prognostic study involving a prospectively recruited cohort of 406 patients consisting of 254 with PAD and 152 without PAD. At the baseline, we measured the plasma concentrations of 17 circulating immunomodulatory proteins and followed the cohort for two years. The primary outcome was 2-year MACE, a composite of myocardial infarction, stroke, or death. Plasma protein concentrations were compared between patients with PAD with and without 2-year MACE using Mann-Whitney U tests. We further examined the prognostic potential of differentially expressed proteins through a Cox proportional hazards analysis, determining their independent associations with 2-year MACE while controlling for all the baseline demographic and clinical characteristics, including the existing coronary artery and cerebrovascular diseases. Additionally, A Kaplan-Meier analysis was performed to evaluate the 2-year freedom from MACE in patients with low versus high levels of the differentially expressed proteins based on the median plasma concentrations. Results: The mean age of the cohort was 68.8 years (SD 11.1), with 134 patients (33%) being female. During the two-year follow-up, 63 individuals (16%) developed MACE. The following proteins were significantly elevated in patients with PAD who experienced 2-year MACE compared to those who did not: galectin-1 (0.17 [SD 0.06] vs. 0.10 [SD 0.07] pg/mL, p = 0.012), alpha-1-microglobulin (16.68 [SD 7.48] vs. 14.74 [SD 6.71] pg/mL, p = 0.019), and galectin-9 (0.14 [SD 0.09] vs. 0.09 [SD 0.05] pg/mL, p = 0.033). The Cox proportional hazards analysis indicated that these three proteins were independently associated with 2-year MACE after adjusting for all the baseline demographic and clinical factors: galectin-1 (HR 1.45 [95% CI 1.09-1.92], p = 0.019), alpha-1-microglobulin (HR 1.31 [95% CI 1.06-1.63], p = 0.013), and galectin-9 (HR 1.35 [95% CI 1.02-1.78], p = 0.028). Over the two-year follow-up, patients with higher levels of galectin-1, galectin-9, and alpha-1-microglobulin had a lower freedom from MACE. Additional analysis showed that these three proteins were not significantly associated with 2-year MACE in patients without PAD. Conclusions: Among the 17 immunomodulatory proteins evaluated, galectin-1, galectin-9, and alpha-1-microglobulin were found to be independently and specifically associated with 2-year MACE in patients with PAD. Assessing the plasma concentrations of these proteins can aid in risk stratification for MACE in patients with PAD, helping to inform clinical decisions regarding multidisciplinary referrals to cardiologists, neurologists, and vascular medicine specialists. This information can also guide the aggressiveness of medical management, ultimately improving cardiovascular outcomes for patients with PAD.

Anticoagulation in device-detected atrial fibrillation with or without vascular disease: a combined analysis of the NOAH-AFNET 6 and ARTESiA trials

BACKGROUND AND AIMS

The optimal antithrombotic therapy in patients with device-detected atrial fibrillation (DDAF) is unknown. Concomitant vascular disease can modify the benefits and risks of anticoagulation.

METHODS

These pre-specified analyses of the NOAH-AFNET 6 (n = 2534 patients) and ARTESiA (n = 4012 patients) trials compared anticoagulation with no anticoagulation in patients with DDAF with or without vascular disease, defined as prior stroke/transient ischaemic attack, coronary or peripheral artery disease. Efficacy outcomes were the primary outcomes of both trials, a composite of stroke, systemic arterial embolism (SE), myocardial infarction, pulmonary embolism or cardiovascular death, and stroke or SE. Safety outcomes were major bleeding or major bleeding and death.

RESULTS

In patients with vascular disease (NOAH-AFNET 6, 56%; ARTESiA, 46%), stroke, myocardial infarction, systemic or pulmonary embolism, or cardiovascular death occurred at 3.9%/patient-year with and 5.0%/patient-year without anticoagulation (NOAH-AFNET 6), and 3.2%/patient-year with and 4.4%/patient-year without anticoagulation (ARTESiA). Without vascular disease, outcomes were equal with and without anticoagulation (NOAH-AFNET 6, 2.7%/patient-year; ARTESiA, 2.3%/patient-year in both randomized groups). Meta-analysis found consistent results across both trials (I2heterogeneity = 6%) with a trend for interaction with randomized therapy (pinteraction = .08). Stroke/SE behaved similarly. Anticoagulation equally increased major bleeding in vascular disease patients [edoxaban, 2.1%/patient-year; no anticoagulation, 1.3%/patient-year; apixaban, 1.7%/patient-years; no anticoagulation, 1.1%/patient-year; incidence rate ratio 1.55 (1.10-2.20)] and without vascular disease [edoxaban, 2.2%/patient-year; no anticoagulation, 0.6%/patient-year; apixaban, 1.4%/patient-year; no anticoagulation, 1.1%/patient-year; incidence rate ratio 1.93 (0.72-5.20)].

CONCLUSIONS

Patients with DDAF and vascular disease are at higher risk of stroke and cardiovascular events and may derive a greater benefit from anticoagulation than patients with DDAF without vascular disease.

Exploring the therapeutic utility of the factor XIa inhibitor asundexian

PURPOSE

Factor XIa inhibitors are a promising novel class of anticoagulants that attenuate pathological thrombosis with minimal interference with hemostasis. These effects contrast with those of conventional anticoagulants, which may exhibit adverse events of untoward bleeding precluding treatment in some patients. A variety of investigational pharmacological modalities have been developed and studied to target factor XIa.

SUMMARY

Asundexian is a small molecule inhibitor of factor XIa that has been evaluated in several clinical studies. It has been studied as an oral, once-daily medication and found to inhibit approximately 90% of factor XIa activity at doses of 20 to 50 mg. Phase 2 trials have demonstrated the potential for improved safety compared to standard of care in certain treatment settings, such as in atrial fibrillation. For other indications, such as noncardioembolic stroke and acute myocardial infarction, asundexian has been used in addition to background antiplatelet therapy. In these instances, asundexian did not show a difference in the incidence of bleeding events compared to placebo.

CONCLUSION

Phase 3 trials have recently been launched; however, the OCEANIC-AF trial was prematurely discontinued due to inefficacy of asundexian vs apixaban for stroke prevention in atrial fibrillation. Another phase 3 trial, OCEANIC-AFINA, is planned to compare asundexian to placebo in patients with atrial fibrillation at high risk for stroke who are deemed ineligible for anticoagulation.

Risk of Intracranial Hemorrhage Associated With Direct Oral Anticoagulation vs Antiplatelet Therapy: A Systematic Review and Meta-Analysis

Importance

For patients with atrial fibrillation, clinicians often prescribe antiplatelet therapy rather than oral anticoagulation, which may be related to a concern that direct oral anticoagulants (DOACs) are associated with a higher risk of intracranial bleeding, despite being less effective for stroke prevention.

Objective

To determine whether DOAC therapy, compared with single-agent antiplatelet therapy, was associated with an increased risk of intracranial and major hemorrhage.

Data Sources

A systematic search of PubMed and Embase databases from inception to February 7, 2024, was performed.

Study Selection

Randomized clinical trials that compared DOAC therapy with single-agent antiplatelet therapies were included. Trials with active follow-up of less than 30 days or a sample size less than 200 were excluded.

Data Extraction and Synthesis

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline. Data were extracted independently by 2 researchers. A random-effects meta-analysis model was used to report pooled treatment effects and 95% CIs.

Main Outcomes and Measures

The primary outcome was occurrence of intracranial hemorrhage.

Results

A total of 9 randomized clinical trials were included (45 494 participants). DOAC therapy was not associated with significantly higher odds of intracranial hemorrhage compared with antiplatelet therapy (0.55% vs 0.48% over a mean trial follow-up of 17.1 months; odds ratio [OR], 1.15; 95% CI, 0.71-1.88), but there was heterogeneity among trials (I2 = 53.7%). In an analysis by DOAC agent, the respective estimates for intracranial hemorrhage risk were as follows: rivaroxaban, OR, 2.09 (95% CI, 1.20-3.64); dabigatran, OR, 1.00 (95% CI, 0.61-1.64); and apixaban, OR, 0.72 (95% CI, 0.44-1.17). Overall, DOAC therapy was associated with higher odds of major hemorrhage compared with antiplatelet therapy (2.41% vs 1.76% over a mean trial follow-up of 15.5 months; OR, 1.39; 95% CI, 1.07-1.80), with the following estimates by agent: rivaroxaban, OR, 1.91 (95% CI, 1.22-3.00); dabigatran; OR, 1.21 (95% CI, 0.86-1.69); and apixaban, OR, 1.09 (95% CI, 0.73-1.63).

Conclusions and Relevance

In this systematic review and meta-analysis, DOAC therapy was not associated with a significantly higher risk of intracranial hemorrhage compared with antiplatelet therapy, but was associated with a higher risk of major hemorrhage. These findings support the safety of DOAC compared with antiplatelet therapy with respect to risk of ICH and reinforce adherence with current atrial fibrillation guidelines.

The prevalent causes of death in patients with peripheral artery disease undergoing revascularisation or amputation

OBJECTIVE

Preventing untimely death in patients with peripheral artery disease (PAD) requires a detailed understanding of the predominant causes of death (COD). This literature review aims to describe how short- and long-term COD are reported in patients who had surgery for PAD.

METHODS

A literature review was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for articles reporting specific causes of mortality in patients who had surgery for all stages of PAD. Articles were included if they reported COD after open surgical or endovascular revascularisation, or major or minor amputation for PAD. Critical appraisals were conducted according to included study types, using the Joanna Briggs Institute tools.

RESULTS

Cause of death was reported in 21 publications. Twenty were observational and one was a randomised control trial. Study size ranged from 25 to 10,505 patients. Cardiovascular disease was the most prevalent COD in perioperative periods (42.5% from 13 studies). Long-term follow-up ranged from 1 month and 7 years with 15 studies reporting cardiac related mortality as the most frequent cause of death. However, mortality from neoplasia, respiratory disease (including pneumonia and pulmonary emboli), stroke and sepsis were prevalent. Many studies were low-average quality, with few population-based observational studies.

CONCLUSION

Whilst cardiovascular COD are the most prevalent reasons for mortality in patients with PAD, the proportion of patients dying from neoplasia and respiratory disease is high. Improved reporting standards for COD in studies examining PAD are needed.

Rivaroxaban plus aspirin after lower-extremity revascularization

INTRODUCTION

Patients undergoing revascularization of the lower extremities have unacceptably high rates of major adverse cardiac and limb events despite the routine use of antiplatelet therapy. Optimization of antithrombotic therapy provides an opportunity to reduce this risk. Recent large, randomized trials have demonstrated substantial benefit from the combination of low-dose rivaroxaban and aspirin compared with aspirin alone. Despite this new evidence, uptake remains limited.

AREAS COVERED

This review will outline the drug profile of rivaroxaban, summarize the key efficacy and safety data for the combination of low-dose rivaroxaban and aspirin following lower extremity revascularization, and examine barriers to therapy uptake.

EXPERT OPINION

Combination of low-dose rivaroxaban and aspirin is the only antithrombotic regimen that has been shown to reduce both cardiac and limb events following peripheral revascularization while maintaining an acceptable bleeding profile. Single and dual antiplatelet therapy have limited randomized evidence for this indication, but are commonly used. An important contributor is the failure of major societal guidelines to incorporate this new evidence. Moving forward, there is an urgent need to update these guidelines. Further evaluation of the efficacy and safety of dual antiplatelet therapy will help to inform optimal antithrombotic therapy after lower extremity revascularization.

Management and Pharmacological Treatment of Peripheral Arterial Disease

Background: Peripheral arterial disease (PAD) is a complex, heterogeneous condition that has become a leading health concern globally. Peripheral arterial disease often co-exists with other vascular disease states, including cerebrovascular and cardiovascular disease. Optimal therapy for managing symptoms and progression of disease employs non-pharmacological, pharmacological, and contemporary revascularisation techniques to improve clinical outcomes and quality of life. However, large well-designed randomised control trials (RCT) and corresponding evidence-based guidelines for management of PAD are lacking, with current practice standards often extrapolated from evidence in coronary artery disease. Purpose: This review article aims to discuss currently accepted best pharmacological practice for PAD. Method: Relevant articles were searched between May 2023 and January 2024 through PubMed, Cochrane Library, Google Scholar and international guidelines, focusing on pharmacological management for PAD. Results: This narrative review discusses holistic pharmacological treatments for PAD.

Factor XIa inhibition as a therapeutic strategy for atherothrombosis

When selecting an anticoagulant, clinicians consider individual patient characteristic, the treatment indication, drug pharmacology, and safety and efficacy as demonstrated in randomized trials. An ideal anticoagulant prevents thrombosis with little or no increase in bleeding. Direct oral anticoagulants represent a major advance over traditional anticoagulants (e.g., unfractionated heparin, warfarin) but still cause bleeding, particularly from the gastrointestinal tract which can limit their use. Epidemiological studies indicate that patients with congenital factor XI (FXI) deficiency have a lower risk of venous thromboembolism (VTE) and ischemic stroke (IS) than non-deficient individuals, and do not have an increased risk of spontaneous bleeding, even with severe deficiency. These observations provide the rationale for targeting FXI as a new class of anticoagulant. Multiple FXI inhibitors have been introduced and several are being evaluated in Phase III trials. In this review, we explain why drugs that target FXI may be associated with a lower risk of bleeding than currently available anticoagulants and summarize the completed and ongoing trials.

Effect of Peripheral Interventions in Patients with Peripheral Artery Disease Receiving Rivaroxaban and Aspirin: Analyses from the XATOA Registry

OBJECTIVE

To assess the characteristics and clinical outcomes of patients with lower extremity peripheral artery disease (PAD) in XATOA receiving dual pathway inhibition (DPI) with rivaroxaban 2.5 mg twice daily plus aspirin according to lower extremity revascularisation (LER) history.

METHODS

XATOA is an international, multicentre, prospective, single arm registry study. This subanalysis investigated patients with lower extremity PAD according to LER history. Patients with coronary artery disease, PAD, or both, receiving DPI were followed for 12 or more months. Baseline characteristics and clinical outcomes were assessed according to LER history. A time dependency analysis assessed outcomes by time between the most recent LER procedure and the start of DPI. A multivariable analysis assessed the influence of patient characteristics on clinical outcomes.

RESULTS

In XATOA (n = 5 532), 2 820 (51.0%) patients had lower extremity PAD, of whom 1 736 (61.6%) had prior LER and 1 084 (38.4%) had no prior LER. Baseline characteristics were generally similar between patients with or without prior LER. A higher proportion of patients with prior LER experienced any treatment emergency clinical events compared with those without prior LER (15.0% vs. 9.4%, respectively), with greater differences observed between incidence rates of limb events, including major adverse limb events (9.06 vs. 4.09 events per 100 patient years, respectively). Similar rates of myocardial infarction, stroke, and major bleeding were observed in both subgroups. Clinical event rates were generally higher in patients who had previous LER for six months or less compared with patients who had previous LET for more than six months before starting DPI, regardless of LER type. Multivariable analyses showed that prior LER was predictive of limb events.

CONCLUSION

This subanalysis of XATOA found that prior LER was associated with increased rates of limb events, consistent with results of COMPASS and VOYAGER PAD. Rates of bleeding were also low regardless of LER history and consistent with the findings from these trials.

Overview and Future Direction of Embolic Stroke of Undetermined Source from the Insights of CHALLENGE ESUS/CS Registry

Cryptogenic stroke (CS) accounts for approximately one-fourth of acute ischemic strokes, with most cases derived from embolic etiologies. In 2014, embolic stroke of undetermined source (ESUS) was advocated and the efficacy of anticoagulant therapy was anticipated. However, 3 large-scale clinical trials failed to demonstrate the superiority of direct oral anticoagulants (DOACs) over aspirin, potentially due to the heterogeneous and diverse pathologies of ESUS, including paroxysmal atrial fibrillation (AF), arteriogenic sources such as nonstenotic carotid plaque and aortic complicated lesion (ACL), patent foramen oval (PFO), and nonbacterial thrombotic endocarditis (NBTE) related to active cancer.Transesophageal echocardiography (TEE) is one of the most effective imaging modalities for assessing embolic sources in ESUS and CS. The Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke (CHALLENGE ESUS/CS) registry is a multicenter registry that enrolled consecutive patients with CS who underwent TEE at 8 hospitals in Japan between April 2014 and December 2016. Their mean age was 68.7±12.8 years, and 455 patients (67.2%) were male. The median National Institutes of Health Stroke Scale (NIHSS) score was 2. Since 7 analyses have been conducted from each institution to date, novel and significant insights regarding embolic origins and pathophysiologies of ESUS and CS were elucidated from this multicenter registry. This review discusses the diagnosis and treatment of ESUS and CS, tracing their past and future directions. Meaningful insights from the CHALLENGE ESUS/CS registry are also referenced and analyzed.

Construction of cytochrome P450 3A and P-glycoprotein knockout rats with application in rivaroxaban-verapamil interactions

Cytochrome P450 3A (CYP3A) and P-glycoprotein (P-gp), as important metabolic enzymes and transporters, participate in the biological transformation and transport of many substances in the body. CYP3A and P-gp are closely related, with very high substrate overlap and regulation similarity, making it particularly difficult to investigate the function of one or the other individually in vivo. Rivaroxaban and verapamil are commonly used together to treat nonvalvular atrial fibrillation in clinical practice. However, this combination therapy can increase systemic exposure to rivaroxaban and the risk of major bleeding and intracranial hemorrhage. In this study, Cyp3a1/2 and Mdr1a/b quadruple gene knockout (qKO) rat model was generated and characterized for the first time. CYP3A1/2 and P-gp are completely absent in this novel rat model. Then, the qKO rat model was applied for the evaluation of the drug-drug interactions (DDI) between rivaroxaban and verapamil. The results demonstrated that CYP3A and P-gp were jointly and selectively involved in the pharmacokinetic interactions between rivaroxaban and verapamil. This study may provide useful information for understanding the role of CYP3A and P-gp in rivaroxaban-verapamil therapy and predicting the potential interaction between CYP3A and P-gp.

Impact of Panvascular Disease on Exercise Capacity and Clinical Outcomes in Patients with Heart Failure with Reduced Ejection Fraction

Background

The aim of this study was to assess the impact of panvascular disease (PVD) on quality of life (QOL), exercise capacity, and clinical outcomes, in patients with heart failure (HF) with reduced ejection fraction (HFrEF).

Methods

We performed a post hoc analysis of the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION; NCT00047437). Patients with PVD were defined as those having coronary heart disease, stroke, or peripheral vascular disease at baseline. Multivariable Cox proportional hazard models were constructed to evaluate the effect of PVD on the primary endpoint (all-cause mortality or hospitalization) and secondary endpoints (all-cause mortality, cardiovascular (CV) mortality or CV hospitalization, and CV mortality or HF hospitalization). Generalized estimating-equation models were constructed to evaluate the effect of PVD on QOL (Kansas City Cardiomyopathy Questionnaire score) and exercise capacity (peak oxygen consumption and 6-minute walk test distance).

Results

Of 2119 patients with chronic HFrEF, 1202 (56.7%) had comorbid PVD. PVD was associated significantly with reduced exercise capacity (P < 0.001). Patients with PVD had a higher risk of all-cause mortality or hospitalization (hazard ratio [HR] 1.15, 95% confidence interval [CI]: 1.02-1.29), CV mortality or CV hospitalization (HR 1.22, 95% CI: 1.07-1.39), and CV mortality or HF hospitalization (HR 1.25, 95% CI: 1.05-1.48), compared with the risk for patients without PVD. Aerobic exercise training did not significantly improve the prognosis of HFrEF patients, in either the PVD or the non-PVD subgroups.

Conclusions

PVD may adversely affect the QOL, exercise capacity, and prognosis of patients with chronic HFrEF.

Secondary prevention therapies following percutaneous coronary intervention or acute coronary syndrome in patients with diabetes mellitus

Diabetes mellitus (DM) promotes atherosclerosis, leading to increased risk for cardiovascular morbidity and mortality. Diabetics represent a challenging subset of patients undergoing percutaneous coronary intervention (PCI) or who have experienced an acute coronary syndrome (ACS), a subset characterized by higher rates of recurrent ischemic events compared with non-diabetics. These events are caused by both patient-related accelerated atherosclerotic disease progression and worse stent-related adverse clinical outcomes translating into a higher risk for repeat revascularization. In addition, DM is paradoxically associated with an increased risk of major bleeding following PCI or an ACS. Secondary prevention therapies following PCI or an ACS in diabetic patients are therefore of paramount importance. This mini review focuses on the currently available evidence regarding short- and long-term secondary prevention treatments for diabetic patients undergoing PCI or who have experienced an ACS.

Direct Oral Anticoagulants: Quick Primer on When to Use and When to Avoid

Direct oral anticoagulants (DOACs) have transformed the landscape of antithrombotic therapy in the past two decades. However, there is uncertainty about when they should or should not be used for treatment or prevention of thromboembolic events. DOACs have largely replaced warfarin for many patients with atrial fibrillation or venous thromboembolism who require anticoagulant therapy. In addition to noninferior efficacy, fewer drug-drug and food-drug interactions and improved convenience; DOACs have been shown to reduce the risk of intracranial hemorrhage. They have also received new indications compared with warfarin, such as cardiovascular risk reduction in patients with stable atherosclerotic diseases. However, there are some scenarios in which DOACs are associated with inferior efficacy or worse safety compared with standard treatment, such as warfarin. These include patients with mechanical heart valves, thrombotic antiphospholipid syndrome, and others. Although DOACs offer a streamlined and convenient option for the management of many patients with or at risk of thromboembolic events, their use should be avoided in certain high-risk scenarios. This minireview summarizes such conditions and those in which there is uncertainty for use of DOACs for particular diseases or particular patient subgroups.

The impact of OCEANIC-AF and the future of factor XIa inhibitors

The OCEANIC-AF trial was terminated early due to inferiority of asundexian compared with apixaban for the prevention of stroke and systemic embolism in patients with atrial fibrillation.1 However, the promisingly low bleeding rates support continued exploration of factor XIa inhibitors. Future efforts should focus on achieving greater factor XIa inhibition and identifying patient populations that may benefit most from these therapies.

Associations Between Dual Antiplatelet Therapy Score and Long-Term Mortality After Percutaneous Coronary Intervention: Analysis of More Than 27,000 Patients

BACKGROUND

The dual antiplatelet therapy (DAPT) score was developed to identify patients undergoing percutaneous coronary intervention (PCI) who are likely to derive benefit (score ≥ 2) or harm (score < 2) from extended DAPT beyond 1 year after PCI in terms of ischemic and bleeding outcomes. We examined the associations between DAPT score at index PCI and long-term mortality from an all-comers PCI registry in patients receiving DAPT according to the standard of care.

METHODS

We retrospectively examined prospectively collected data from the Melbourne Interventional Group PCI database (2005-2018) and grouped patients as having DAPT score ≥ 2 or < 2. Long-term mortality was assessed from the Australian National Death Index linkage. The primary end point was long-term mortality as determined using survival analysis. Secondary end points included in-hospital events and 30-day major adverse cardiac events (MACE), a composite of death, myocardial infarction, or target vessel revascularisation.

RESULTS

Of 27,740 study patients, 9402 (33.9%) had DAPT score ≥ 2. Patients with DAPT score ≥ 2 were younger, included more women, and had a higher prevalence of cardiovascular risk factors. Patients with DAPT score ≥ 2 had higher in-hospital mortality (3.0% vs 1.0%), major bleeding (2.3% vs 1.6%), 30-day MACE (7.1% vs 3.1%), and long-term mortality at a median follow-up of 5.17 years (21.9% vs 16.5%) P < 0.001 for all.

CONCLUSIONS

One-third of all-comer patients undergoing PCI had a DAPT score ≥ 2 with greater short-term ischemic and bleeding risk, and higher long-term mortality. Risk assessment with the DAPT score may guide the duration and intensity of DAPT beyond the early post-PCI period.

Recurrent cardiovascular and limb events in 294,428 patients with coronary or peripheral artery disease or ischemic stroke on antiplatelet monotherapy: The RESRISK cohort study

BACKGROUND AND AIMS

Utilising real-world data, we quantified the burden of cardiovascular risk factors and long-term residual risk of atherothrombotic events among routine care cohorts with coronary (CAD) or peripheral (PAD) artery disease or ischemic stroke (IS) on guideline-recommended antiplatelet monotherapy (APMT).

METHODS

Retrospective cohort study using data (2010-2020) from the United Kingdom Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics, including adults with CAD, PAD or IS who were first prescribed APMT (CAD/IS: aspirin; PAD: clopidogrel). Primary outcomes (recurrent events): major adverse cardiovascular events (MACE) for CAD/PAD/IS cohorts, major adverse limb events (MALE) for PAD.

RESULTS

266,478 CAD, 13,162 PAD, and 14,788 IS patients were included (mean age: 71 years; women 37.7%-47.5 %). Risk factor burden was high and attainment of recommended goals was low. There were 73,691, 3,121 and 7,137 MACE among CAD, PAD and IS patients, respectively (median follow-up: 89.9, 42.4 and 75.9 months, respectively), and 4,767 MALE among PAD patients. MACE incidence rate per 1000 person-years was higher in IS (268.7; 95%CI 265.3-272.0) than CAD (92.9; 95%CI 92.5-93.4) or PAD cohorts (97.2; 95%CI 94.6-99.8). MALE incidence rate was 195.9 (95%CI 192.2-199.6) per 1000 person-years. IS patients presented a lower rate of hospitalisations and longer time-to-first hospitalisation, but once hospitalised, they had a longer length-of-stay. PAD patients had the highest hospitalisation rate.

CONCLUSIONS

Among a contemporary cohort with cardiovascular disease on APMT, long-term residual atherothrombotic risk remains high despite being on APMT. Greater attention to risk factor control and use of appropriate evidence-based therapy is required to reduce residual risk among this very high-risk population.

Patient Acceptance and Adherence to the COMPASS Trial Drug Recommendations Following Symptomatic Carotid Endarterectomy

BACKGROUND

The COMPASS trial demonstrated that in patients with atherosclerotic diseases, low-dose rivaroxaban and aspirin provides greater protection against subsequent major adverse cardiovascular events (MACEs) than mono-antiplatelet therapy (MAPT) alone. Drug acceptance and adherence maximizes this benefit. We have assessed drug acceptance and adherence to the COMPASS drug regime in patients following carotid endarterectomy (CEA) for symptomatic carotid artery stenosis.

METHODS

Following CEA, the views of 63 patients on the COMPASS drug regime were assessed using the Beliefs about Medicine Questionnaire and drug adherence was determined using the Sidorkiewicz scoring system. These views were compared with those of 54 patients on MAPT. Side effects (bleeding and drug reactions) and new MACE were recorded.

RESULTS

Post-CEA patients on the COMPASS drug regimen had strong positive views on the necessity to take these drugs (necessity scale 19.6 ± 3.6). Although there were some concerns about the COMPASS drug regimen, these were not strongly held (concern cscale 11.8 ± 4.9) and the necessity-concerns differential was positive (7.8 ± 6.2). The Drug Adherence Score was "High" to "Good" (level of drug adherence 1.7 ± 1.0). The Beliefs about Medicine Questionnaire scales and Drug Adherence Score of post-CEA patients on the COMPASS drug regimen were similar to those on MAPT. The incidence of post-CEA MACE and side effects were similar for those on the COMPASS drug regimen and MAPT.

CONCLUSIONS

Post-CEA patients on the COMPASS drug regimen had positive views on taking the drugs and drug adherence was high. We did not identify any patient-related barriers to the use of the COMPASS drug regimen to further reduce cardiovascular events.

Antithrombotics and Gastrointestinal Prophylaxis: A Systematic Review

Antithrombotic medications include both antiplatelet and anticoagulants and are used for a wide variety of cardiovascular conditions. A common complication of antithrombotic use is gastrointestinal bleeding. As a result, gastrointestinal prophylaxis is a common consideration for patients on a single or combination antithrombotic regimen. Prophylaxis is typically achieved through use of either proton pump inhibitors or histamine 2 receptor antagonists. Current recommendations for use of gastrointestinal prophylaxis with concomitant use of antithrombotic medications are scarce. In this systematic review, we explore the current evidence and recommendations regarding gastrointestinal prophylaxis for patients on antiplatelet or anticoagulant therapy as well as combination regimens.

Results of the COMPASS Trial Analyzed Using Win Ratio Compared With Conventional Analytic Approaches

BACKGROUND

Win ratio (WR) is a newer analytic approach for trials with composite end points that accounts for the relative importance of individual components. Our objective was to compare the results of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial analyzed using WR with those obtained using conventional statistical approaches.

METHODS

We used an unmatched WR analysis for first and total (first plus recurrent) events to examine effects of rivaroxaban with aspirin and rivaroxaban alone vs aspirin alone on primary efficacy (cardiovascular death, stroke, myocardial infarction), safety (modified International Society on Thrombosis and Haemostasis major bleeding), and net clinical benefit (primary efficacy plus fatal or critical organ bleeding) end points. We compared the WR results with those obtained using the Cox proportional hazards regression model for first events and Anderson-Gill method for total events. We calculated the win difference to estimate absolute treatment effects.

RESULTS

The WR approach produced results consistent with those obtained using conventional statistical methods for the primary composite end point (first event: WR, 1.32 [95% confidence interval (CI), 1.14-1.52]; 1/Cox hazard ratio, 1.32 [95% CI, 1.16-1.52]; total [first plus recurrent] events: WR, 1.32 [95% CI, 1.14-1.52]; 1/Anderson-Gill hazard ratio, 1.32 [95% CI, 1.16-1.54]) as well as for main safety and net clinical benefit end points. The absolute benefits of the combination of rivaroxaban and aspirin compared with aspirin alone calculated using the win difference were greatest in those with multiple high-risk features.

CONCLUSIONS

Reanalysis of the COMPASS trial results using WR produced results that were consistent with those obtained using conventional statistical approaches.

CLINICAL TRIAL REGISTRATION

NCT01776424.

A systematic review and meta-analysis of the morbidity of efficacy endpoints and bleeding events in elderly and young patients treated with the same dose rivaroxaban

Rivaroxaban is a new direct oral anticoagulant, and the same dose is recommended for older and young patients. However, recent real-world studies show that older patients may need dose adjustment to prevent major bleeding. At present, the evidence for dose adjustment in older patients is extremely limited with only a few reports on older atrial fibrillation patients. The aim of this study was to review the morbidity data of adverse events and bleeding events across all indications for older and young patients treated with the same dose of rivaroxaban to provide some support for dosage adjustment in older patients. The PubMed, EMBASE, ClinicalTrials, Cochrane and Web of Science databases were searched for randomized controlled trials (RCTs) published between January 1, 2005, and October 10, 2023. The primary outcomes were the morbidity of bleeding events and efficacy-related adverse events. Summary estimates were calculated using a random effects model. Eighteen RCTs were included in the qualitative analysis. The overall morbidity of primary efficacy endpoints was higher in older patients compared to the young patients (3.37% vs. 2.60%, χ2 = 5.24, p = 0.022). Similarly, a higher morbidity of bleeding was observed in older patients compared to the young patients (4.42% vs. 6.03%, χ2 = 13.22, p < 0.001). Among all indications, deep vein thrombosis, pulmonary embolism and atrial fibrillation were associated with the highest incidence of bleeding in older patients, suggesting that these patients may be most need dose adjustment. Patients older than 75 years may require extra attention to prevent bleeding. The same dose of rivaroxaban resulted in higher bleeding morbidity and morbidity of efficacy-related adverse events in older patients compared to the young patients. An individualized dose adjustment may be preferred for older patients rather than a fixed dose that fits all.

Should We Use Aspirin or P2Y12 Inhibitor Monotherapy in Stable Ischemic Heart Disease?

PURPOSE OF REVIEW

To summarize the recent evidence and guideline recommendations on aspirin or P2Y12 inhibitor monotherapy in patients with stable ischemic heart disease and provide insights into future directions on this topic, which involves transition to a personalized assessment of bleeding and thrombotic risks.

RECENT FINDINGS

It has been questioned whether the evidence for aspirin as the foundational component of secondary prevention in patients with coronary artery disease aligns with contemporary pharmaco-invasive strategies. The recent HOST-EXAM study randomized patients who had received dual antiplatelet therapy for 6 to 18 months without ischemic or major bleeding events to either clopidogrel or aspirin for a further 24 months, and demonstrated that the patients in the clopidogrel arm had significantly lower rates of both thrombotic and bleeding complications compared to those in the aspirin arm. The patient-level PANTHER meta-analysis showed that in patients with established coronary artery disease, P2Y12 inhibitor monotherapy was associated with lower rates of myocardial infarction, stent thrombosis as well as gastrointestinal bleeding and hemorrhagic stroke compared to aspirin monotherapy, albeit with similar rates of all-cause mortality, cardiovascular mortality and major bleeding. Long-term low-dose aspirin is recommended for secondary prevention in patients with stable ischemic heart disease, with clopidogrel monotherapy being acknowledged as a feasible alternative. Dual antiplatelet therapy for six months after percutaneous coronary intervention remains the standard recommendation for patients with stable ischemic heart disease. However, the duration of dual antiplatelet therapy may be shortened and followed by P2Y12 inhibitor monotherapy or prolonged based on individualized evaluation of the patient's risk profile.

Brazilian Society of Angiology and Vascular Surgery guidelines on peripheral artery disease

Patients with peripheral artery disease and generalized atherosclerosis are at high risk of cardiovascular and limb complications, affecting both quality of life and longevity. Lower limb atherosclerotic disease is associated with high cardiovascular morbidity and mortality and adequate management is founded on treatments involving patient-dependent factors, such as lifestyle changes, and physician-dependent factors, such as clinical treatment, endovascular treatment, or conventional surgery. Medical management of peripheral artery disease is multifaceted, and its most important elements are reduction of cholesterol level, antithrombotic therapy, control of arterial blood pressure, control of diabetes, and smoking cessation. Adhesion to this regime can reduce complications related to the limbs, such as chronic limb-threatening ischemia, that can result in amputation, and the systemic complications of atherosclerosis, such as stroke and myocardial infarction.

Antithrombotic Therapy in High Bleeding Risk, Part II: Noncardiac Percutaneous Interventions

Over the past decades, there have been great advancements in the antithrombotic management of patients undergoing percutaneous interventions, but most of the available evidence derives from studies conducted in the setting of cardiac interventions. Antithrombotic treatment regimens used in patients undergoing percutaneous cardiac interventions, in particular coronary, are frequently extrapolated to patients undergoing noncardiac interventions. However, the differences in risk profile of the population treated and the types of interventions performed may translate into differences is the safety and efficacy associated with antithrombotic therapy. Noncardiac percutaneous interventions are commonly performed in patients at high bleeding risk, which may indeed impact outcomes, hence underscoring the importance of risk stratification to guide clinical decision-making processes. In this review, we appraise the available evidence on antithrombotic therapy in high-bleeding-risk patients undergoing noncardiac percutaneous interventions.

Adverse events analysis of Relugolix (Orgovyx®) for prostate cancer based on the FDA Adverse Event Reporting System (FAERS)

BACKGROUND

Due to the limitations of clinical trials, some delayed and rare adverse events (AEs) may remain undetected, and safety information can be supplemented through post-market data analysis. This study aims to comprehensively analyze the AEs associated with Relugolix (Orgovyx®) using data from the FAERS database, and gain a better understanding of the potential risks and side effects of Relugolix (Orgovyx®) therapy.

METHODS

Data of Relugolix (Orgovyx®) were collected from the FAERS database covering the period from the fourth quarter of 2020 to the third quarter of 2023. Disproportionality analysis was performed by calculating the reporting odds ratios (ROR), proportional reporting ratio (PRR), Bayesian analysis confidence propagation neural network (BCPNN), and the multi-item gamma Poisson shrinker (MGPS) to detect positive signals.

RESULTS

Totally, 5,382,189 reports were collected from the FAERS database, 4,397 reports of Relugolix (Orgovyx®) were identified as the 'primary suspected (PS)' AEs. Relugolix (Orgovyx®) induced AEs occurred in 26 organ systems. 58 significant disproportionality preferred terms (PTs) satisfying with the four algorithms were retained at the same time. Unexpected significant AEs such as Pollakiuria, and Prostatic specific antigen increased also occur. The median time of onset was 60 days. The majority of the AEs occurred within the first 30 days after Relugolix (Orgovyx®) initiation.

CONCLUSION

Common AEs included Hot flush, Fatigue, Asthenia, Constipation, and Myalgia. These AEs should be focused on when using the drug to avoid serious consequences. In addition, the study results also suggested that the drug may exist Pollakiuria, Prostatic specific antigen increased and other AEs not mentioned in the manual, to supplement the AEs in the manual. This study is helpful for clinicians and pharmacists to improve their understanding of Relugolix (Orgovyx®) related AEs, and take timely prevention and treatment measures to ensure drug safety for patients.

eIF6 deficiency regulates gut microbiota, decreases systemic inflammation, and alleviates atherosclerosis

Altered composition of the gut microbiota affects immunity and metabolism. This study previously found that eIF6 gene knockdown changes the composition of the intestinal flora in the eIF6 gene knockdown mouse model. Lactobacillus acidophilus is significantly increased in the model. This study was designed to investigate the role of L. acidophilus in the pathogenesis of atherosclerosis. Transcriptomic data from 117 patients with coronary artery disease (CAD) and 79 healthy individuals were obtained. ApoE-/- and ApoE-/-/eIF6+/- mice on normal chow diet or a high-fat diet were treated for 16 weeks; eIF6 deficiency was evaluated atherosclerosis. ApoE-/- mice on normal chow diet or a high-fat diet were treated with L. acidophilus by daily oral gavage for 16 weeks. Moreover, one group was treated with lipopolysaccharide at 12 weeks. The levels of eIF6, RNASE3, and RSAD2 were notably higher in the patients with CAD than in the healthy individuals. eIF6 deficiency altered the composition of gut microbiota. eIF6 deficiency reduced the atherosclerotic lesion formation in ApoE-/-/eIF6+/- mice compared with the ApoE-/- mice. The microbial sequencing and metabolomics analysis demonstrated some beneficial bacterial (L. acidophilus, Ileibacterium, and Bifidobacterium) and metabolic levels significantly had deference in ApoE-/-/eIF6+/- mice compared with the ApoE-/- mice. Correlational studies indicated that L. acidophilus had close correlations with low-density lipoprotein cholesterol, lesion area, and necrotic area. L. acidophilus inhibited high-fat diet-induced inflammation and atherosclerotic lesion, increasing the expression of tight junction proteins (ZO-1 and claudin-1) and reducing the gut permeability. However, lipopolysaccharide reversed the protective effect of L. acidophilus against atherosclerosis. eIF6 deficiency protected against atherosclerosis by regulating the composition of gut microbiota and metabolites. L. acidophilus attenuated atherosclerotic lesions by reducing inflammation and increasing gut permeability.IMPORTANCEeIF6 deficiency modulates the gut microbiota and multiple metabolites in atherosclerotic ApoE-/- mice. L. acidophilus was reduced in the gut of atherosclerotic ApoE-/- mice, but administration of Lactobacillus acidophilus reversed intestinal barrier dysfunction and vascular inflammation. Our findings suggest that targeting individual species is a beneficial therapeutic strategy to prevent inflammation and atherosclerosis.

Improving analysis of cognitive outcomes in cardiovascular trials using different statistical approaches

BACKGROUND

The Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) questionnaires are commonly used to measure global cognition in clinical trials. Because these scales are discrete and bounded with ceiling and floor effects and highly skewed, their analysis as continuous outcomes presents challenges. Normality assumptions of linear regression models are usually violated, which may result in failure to detect associations with variables of interest.

METHODS

Alternative approaches to analyzing the results of these cognitive batteries include transformations (standardization, square root, or log transformation) of the scores in the multivariate linear regression (MLR) model, the use of nonlinear beta-binomial regression (which is not dependent on the assumption of normality), or Tobit regression, which adds a latent variable to account for bounded data. We aim to empirically compare the model performance of all proposed approaches using four large randomized controlled trials (ORIGIN, TRANSCEND, COMPASS, and NAVIGATE-ESUS), and using as metrics the Akaike information criterion (AIC). We also compared the treatment effects for the methods that have the same unit of measure (i.e., untransformed MLR, beta-binomial, and Tobit).

RESULTS

The beta-binomial consistently demonstrated superior model performance, with the lowest AIC values among nearly all the approaches considered, followed by the MLR with square root and log transformations across all four studies. Notably, in ORIGIN, a substantial AIC reduction was observed when comparing the untransformed MLR to the beta-binomial, whereas other studies had relatively small AIC reductions. The beta-binomial model also resulted in a significant treatment effect in ORIGIN, while the untransformed MLR and Tobit regression showed no significance. The other three studies had similar and insignificant treatment effects among the three approaches.

CONCLUSION

When analyzing discrete and bounded outcomes, such as cognitive scores, as continuous variables, a beta-binomial regression model improves model performance, avoids spurious significance, and allows for a direct interpretation of the actual cognitive measure.

TRIALS REGISTRATION

ORIGIN (NCT00069784). Registered on October 1, 2003; TRANSCEND (NCT00153101). Registered on September 9, 2005; COMPASS (NCT01776424). Registered on January 24, 2013; NAVIGATE-ESUS (NCT02313909). Registered on December 8, 2014.

Dual Antithrombotic Therapy versus Anticoagulant Monotherapy for Major Adverse Limb Events in Patients with Concomitant Lower Extremity Arterial Disease and Atrial Fibrillation: A Propensity Score Weighted Analysis

OBJECTIVE

Patients with symptomatic lower extremity arterial disease (LEAD) are recommended to receive antiplatelet therapy, while direct oral anticoagulants (DOACs) are standard for stroke prevention in patients with atrial fibrillation (AF). For patients with concomitant LEAD and AF, data comparing dual antithrombotic therapy (an antiplatelet agent used in conjunction with a DOAC) vs. DOAC monotherapy are scarce. This retrospective cohort study, based on data from the Taiwan National Health Insurance Research Database, aimed to compare the efficacy and safety of these antithrombotic strategies.

METHODS

Patients with AF who underwent revascularisation for LEAD between 2012 - 2020 and received any DOAC within 30 days of discharge were included. Patients were grouped by antiplatelet agent exposure into the dual antithrombotic therapy and DOAC monotherapy groups. Inverse probability of treatment weighting was used to mitigate selection bias. Major adverse limb events (MALEs), ischaemic stroke or systemic embolism, and bleeding outcomes were compared. Patients were followed until the occurrence of any study outcome, death, or up to two years.

RESULTS

A total of 1 470 patients were identified, with 736 in the dual antithrombotic therapy group and 734 in the DOAC monotherapy group. Among them, 1 346 patients received endovascular therapy as the index revascularisation procedure and 124 underwent bypass surgery. At two years, dual antithrombotic therapy was associated with a higher risk of MALEs than DOAC monotherapy (subdistribution hazard ratio [SHR] 1.34, 95% confidence interval [CI] 1.15 - 1.56), primarily driven by increased repeat revascularisation. Dual antithrombotic therapy was also associated with a higher risk of major bleeding (SHR 1.43, 95% CI 1.05 - 1.94) and gastrointestinal bleeding (SHR 2.17, 95% CI 1.42 - 3.33) than DOAC monotherapy.

CONCLUSION

In patients with concomitant LEAD and AF who underwent peripheral revascularisation, DOAC monotherapy was associated with a lower risk of MALEs and bleeding events than dual antithrombotic therapy.

Sex and gender bias in chronic coronary syndromes research: analysis of studies used to inform the 2019 European Society of Cardiology guidelines

Background

Sex and gender inequalities in ischemic heart diseases persist. Although ischemic heart disease is less common in women, they experience worse clinical outcomes and are less likely to receive guideline-recommended treatments. The primary scientific literature from which clinical guideline recommendations are derived may not have considered potential sex- and gender biases. This study aims to determine whether the literature cited in recent cardiovascular guidelines' clinical recommendations contain sex and gender biases.

Methods

We analysed publications cited in the 2019 European Society of Cardiology (ESC) guideline recommendations on chronic coronary syndromes, using a checklist to guide data extraction and evaluate the individual studies for sex- and gender-related aspects, such as inclusion/exclusion criteria, outcome measures, and demographic data reporting. To assess representation over time, the proportion of women participants in each study was computed and analysed using a beta regression model. We also examined the associations between women's representation, journal impact factor and author gender.

Findings

Among the 20 ESC recommendations on chronic coronary syndromes, four contained sex-related statements; we did not identify any gender-specific suggestions. The referenced literature upon which these recommendations were based consisted of 108 articles published between 1991 and 2019, encompassing more than 1.6 million study participants (26.8%; 432,284 women). Only three studies incorporated sex-sensitive designs; none were gender-specific. The term "gender" did not occur in 84% (n = 91/108) of the publications; when used, it was exclusively to denote biological sex. The proportion of women (assumed by investigators) among study participants fluctuated over time. Having a woman as first (odds ratio (OR) = 1.68, 95% CI: 1.19-2.39) or last author (OR = 2.28, 95% CI: 1.31-3.97), was significantly associated with having more women participants in the study.

Interpretation

The data underlying ESC guideline recommendations largely lack reporting of possible sex- and gender-specific aspects, and women are distinctly underrepresented. To what extent these recommendations apply to members of specific population groups who are not well-represented in the underlying evidence base remains unknown.

Funding

This study is part of the Gender and Health Inequalities (GENDHI) project, ERC-2019-SyG. This project has received funding from the European Research Council (ERC).

Antithrombotic Therapy in Patients with Chronic Coronary Syndromes

The antithrombotic management of chronic coronary syndrome (CCS) involves a 6-month course of dual antiplatelet therapy (DAPT), followed by chronic aspirin therapy. In patients with a baseline indication for anticoagulation, a variable duration of triple antithrombotic therapy is administered, followed by dual antithrombotic therapy until the sixth month post-percutaneous coronary intervention (PCI), and ultimately a transition to chronic anticoagulation. However, advancements in stent technology reducing the risk of stent thrombosis and a growing focus on the impact of bleeding on prognosis have prompted the development of new therapeutic strategies. These strategies aim to enhance protection against ischemic events in the initial stages after PCI while mitigating the risk of bleeding in the long term. This article delineates the therapeutic strategies outlined in European and American guidelines for CCS management, with special attention to investigational strategies.

Medical Optimization of Patients with Symptomatic Peripheral Arterial Disease

Peripheral artery disease (PAD) is a progressive disease associated with the occurrence of major adverse cardiovascular and limb events and elevated mortality rates. Symptoms of PAD, including claudication and chronic limb-threatening ischemia, impair functional capacity and lead to lower quality of life. The focus of current therapies is to minimize symptoms, improve quality of life, and reduce adverse cardiovascular and limb events. Among the medical therapies are antiplatelets, anticoagulants, antihypertensives, lipid lowering therapies, cilostazol and pentoxifylline, and novel blood sugar-lowering therapies, plus exercise therapy and smoking cessation. In this review, we discuss these evidence-based medical therapies that are available for patients with symptomatic PAD.

Editorial: Incidence and predictors of major gastrointestinal bleeding in patients on aspirin, low-dose rivaroxaban or the combination: Secondary analysis of the COMPASS randomised controlled trial

This article is linked to Forbes et al paper. To view this article, visit https://doi.org/10.1111/apt.18139

2023 European Society of Cardiology guidelines for the management of acute coronary syndromes : Statement of endorsement by the NVVC

This review discusses the new recommendations in the 2023 European Society of Cardiology guidelines on the management of acute coronary syndrome and provides a perspective on topics specific to clinical practice in the Netherlands, including pre-treatment, antiplatelet agent strategies, the use of risk scores and logistical considerations with regard to the timing of coronary angiography.

Patient Factors Influencing Prescription of Antithrombotic Medication After Lower Limb Endovascular Intervention

OBJECTIVE

There is significant practice variation in the use of antithrombotic therapy after endovascular intervention for lower limb peripheral arterial disease, with differences in medication choice and duration. Prescriber decision making is complex, and patient factors have been shown to substantially contribute to prescribing variation. To determine the influence of patient factors on antithrombotic prescribing, a discrete choice experiment was distributed to vascular surgeons and trainees across Australia and Aotearoa New Zealand.

METHODS

After pilot testing, the discrete choice experiment questionnaire was distributed to 300 vascular surgeons and trainee members of the Australian and New Zealand Society for Vascular Surgery. Multinomial logistic regression models were used to analyse patient factors that had the most influence on decisions to prescribe a second antithrombotic agent, and the preferred choice of antithrombotic (clopidogrel 75 mg daily or rivaroxaban 2.5 mg twice daily) in addition to aspirin 100 mg daily. The odds ratio (OR) with 95% confidence interval (CI) reported preference strength.

RESULTS

A total of 44 questionnaires were completed between September and October 2023, reaching the 15% targeted response rate. Prescribing a second antithrombotic was more likely after femoropopliteal stenting compared with angioplasty (OR 1.89, 95% CI 1.20 - 2.13), and in chronic limb threatening ischaemia compared with intermittent claudication (OR 1.58, 95% CI 1.20 - 2.13). Most respondents preferred clopidogrel over rivaroxaban (62%), with over a third of respondents exclusively prescribing clopidogrel. Patients with stents (OR 1.77, 95% CI 1.32 - 2.37) or moderate bleeding risk (OR 1.38, 95% CI 0.97 - 1.84) were more likely to receive clopidogrel than rivaroxaban.

CONCLUSION

This study demonstrates that vascular surgeons primarily prioritise antithrombotic prescribing decisions by procedure type. Clopidogrel is more likely to be prescribed than rivaroxaban as a second agent in combination with aspirin, especially after stenting. Knowing these clinician preferences can target implementation strategies towards supporting decision making in subgroups of patients according to individual risk profiles.

Regulation of Platelet Activation and Coagulation: Current Concepts, Novel Targets, and Therapies

Antiplatelet and anticoagulant therapies are cornerstones of secondary prevention in high-risk cardiovascular patients. Whereas in former days the focus was set on effective antithrombotic effects, more recent trials and guidelines placed emphasis on a more balanced approach, thus including the bleeding risk for an individualized therapy. Type, strength, combination, and duration are important components to modify the individual bleeding risk. Novel antiplatelet and anticoagulant agents have shown promising results that might offer safer options in the future for high-risk cardiovascular patients. This review aims to give an overview about established drug target and pharmacologic approaches that are currently in the pipeline.

DCRM 2.0: Multispecialty practice recommendations for the management of diabetes, cardiorenal, and metabolic diseases

The spectrum of cardiorenal and metabolic diseases comprises many disorders, including obesity, type 2 diabetes (T2D), chronic kidney disease (CKD), atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), dyslipidemias, hypertension, and associated comorbidities such as pulmonary diseases and metabolism dysfunction-associated steatotic liver disease and metabolism dysfunction-associated steatohepatitis (MASLD and MASH, respectively, formerly known as nonalcoholic fatty liver disease and nonalcoholic steatohepatitis [NAFLD and NASH]). Because cardiorenal and metabolic diseases share pathophysiologic pathways, two or more are often present in the same individual. Findings from recent outcome trials have demonstrated benefits of various treatments across a range of conditions, suggesting a need for practice recommendations that will guide clinicians to better manage complex conditions involving diabetes, cardiorenal, and/or metabolic (DCRM) diseases. To meet this need, we formed an international volunteer task force comprising leading cardiologists, nephrologists, endocrinologists, and primary care physicians to develop the DCRM 2.0 Practice Recommendations, an updated and expanded revision of a previously published multispecialty consensus on the comprehensive management of persons living with DCRM. The recommendations are presented as 22 separate graphics covering the essentials of management to improve general health, control cardiorenal risk factors, and manage cardiorenal and metabolic comorbidities, leading to improved patient outcomes.

Myocardial ischaemic syndromes: a new nomenclature to harmonize evolving international clinical practice guidelines

Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischaemia, various classifications have emerged over time, often with conflicting terminology-e.g. 'stable coronary artery disease' (CAD), 'stable ischaemic heart disease', and 'chronic coronary syndromes' (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with 'acute coronary syndromes' (ACS), the 2023 American guidelines endorsed the alternative term 'chronic coronary disease'. An unintended consequence of these competing classifications is perpetuation of the restrictive terms 'coronary' and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischaemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of 'acute myocardial ischaemic syndromes' and 'non-acute myocardial ischaemic syndromes', which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischaemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischaemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischaemia and infarction.

Three-Year Safety and Efficacy of Endovascular Treatment of Common Femoral Artery in 150 PAD Patients

Background: The gold standard treatment for peripheral arterial disease (PAD) of the common femoral artery (CFA) is open common femoral endarterectomy (CFAE). Interest in the less invasive endovascular treatment (EVT) is growing due to PAD patients' frequent co-morbidities. Aims: We aimed to evaluate three-year EVT outcomes in multimorbid PAD patients with severe calcified CFA lesions. Methods: Using the prospectively maintained "all-comers" Duesseldorf PTA Registry, we analysed the three-year outcomes of 150 patients with EVT of the CFA. Between January 2017 and October 2023, 66 patients received a rotational excisional atherectomy (REA) followed by a drug-coated balloon angioplasty (DCB), and 84 patients received a DCB alone. Results: All procedures involved the CFA, 49% additionally involved the proximal superficial femoral artery (SFA), and 10% of the lesions involved the profunda femoris artery (PFA). The procedural success rate was 97% and independent of PAD stage, with a higher level of stent implantation in the DCB group (58% vs. 39%, p < 0.05). The primary patency rate at one year was 83% for REA + DCB and 87% for DCB (p = 0.576), while secondary patency after three years was 97%. The MALE rate at three years was mainly driven by cdTLR (REA + DCB: (20%) vs. DCB: (14%), p = 0.377), while major amputations were low in both groups (REA + DCB: 3% vs. DCB: 1%). Overall, the major adverse cardiovascular events (MACEs) rate at three years was low (REA + DCB: (5%) vs. DCB: (11%), p = 0.170). Conclusions: The EVT of severely calcified CFA lesions is safe and effective, with high three-year patency rates and low rates of major adverse limb events (MALEs) and MACEs. This registry demonstrates that vessel preparation with REA minimizes the need for stenting.

Clopidogrel Versus Aspirin as Chronic Maintenance Antiplatelet Monotherapy in Patients After Percutaneous Coronary Intervention With Chronic Kidney Disease: A Post Hoc Analysis of the HOST-EXAM Trial

BACKGROUND

Clopidogrel monotherapy improved clinical outcomes compared with aspirin monotherapy during a chronic maintenance period in patients who underwent coronary stenting in the HOST-EXAM (Harmonizing Optimal Strategy for Treatment of Coronary Artery Stenosis-Extended Antiplatelet Monotherapy) trial. However, it is uncertain whether the beneficial effect of clopidogrel over aspirin is different according to the renal function.

METHODS AND RESULTS

We conducted a post hoc analysis of the HOST-EXAM trial. Chronic kidney disease (CKD) was defined as baseline estimated glomerular filtration rate <60 mL/min per 1.73 m2. The primary end point was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium bleeding type ≥3, during the 2-year follow up. Among the 5438 patients enrolled in the HOST-EXAM trial, 4844 patients (mean age, 63.3±10.6 years; 74.9% men) with a baseline creatinine value were analyzed in this study. A total of 508 (10.5%) patients had CKD, who were at higher risk of the primary end point compared with those without CKD (hazard ratio [HR], 2.01 [95% CI, 1.51-2.67]). Clopidogrel monotherapy was associated with a lower rate of the primary end point in both patients with CKD (HR, 0.74 [95% CI, 0.44-1.25]) and patients without CKD (HR, 0.71 [95% CI, 0.56-0.91]). No significant interaction was observed between the treatment effect and CKD status (P for interaction=0.889).

CONCLUSIONS

During the chronic maintenance period after coronary stenting, the risk of thrombotic and bleeding events was significantly higher in patients with CKD compared with those without CKD. There was no statistical difference in the treatment effect of clopidogrel monotherapy in those with versus without CKD.