2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients With Atrial Fibrillation or Venous Thromboembolism Undergoing Percutaneous Coronary Intervention or With Atherosclerotic Cardiovascular Disease

Direct oral anticoagulant and antiplatelet therapy for extracranial neurovascular stenting in patients with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is a common comorbidity in patients with extracranial neurovascular disease. When these patients require interventional procedures, the optimal perioperative anticoagulation regimen remains unclear. This study evaluates the safety and efficacy of a perioperative antithrombotic strategy for non-valvular atrial fibrillation (NVAF) patients undergoing carotid artery stenting (CAS) or vertebral artery stenting (VAS).

METHODS

We retrospectively analyzed clinical data from NVAF patients treated with CAS/VAS between January 2018 and June 2023. The pre-procedural regimen included aspirin (100 mg/day), clopidogrel (75 mg/day), and prophylactic low molecular weight heparin (LMWH). Post-procedural therapy combined a novel oral anticoagulant (NOAC) with a P2Y12 inhibitor.

RESULTS

Thirty patients (71.3 ± 6.9 years; 93.3% male) achieved technical success. Complications included one hemorrhage and one unexplained cerebral embolism. No acute/subacute stent thrombosis or restenosis occurred within 3 months.

CONCLUSIONS

Dual antithrombotic therapy (NOAC + P2Y12 inhibitor) post-procedure may balance efficacy and safety in NVAF patients undergoing CAS/VAS. Larger studies are needed for validation.

The critical role of platelets in venous thromboembolism: Pathogenesis, clinical status, and emerging therapeutic strategies

Venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), is a complex vascular disorder with high morbidity and mortality, driven by Virchow's Triad: blood stasis, hypercoagulability, and endothelial injury. VTE is now recognized as an inflammatory process involving multiple components. Platelets are involved in the process of VTE, contributing to thrombosis initiation, progression, resolution and recurrence through coagulation activation, and interactions with immune and endothelial cells. Anticoagulation remains the cornerstone of VTE treatment; however, antiplatelet agents like aspirin have demonstrated therapeutic potential, particularly following major orthopedic surgeries. Furthermore, emerging platelet-targeted therapies and biomarkers offer new opportunities for improving VTE diagnosis and treatment. This review explores the evolving role of platelets in VTE pathophysiology, assesses current antiplatelet strategies, and highlights novel therapeutic approaches. Advancing platelet research in VTE may lead to safer, more effective interventions, optimizing outcomes for patients with this life-threatening condition.

An Intervention to Reduce Antiplatelet Use without Gastroprotection in Patients Using Warfarin: The AEGIS Cluster Randomized Trial

Many patients receiving anticoagulants take antiplatelet medications unnecessarily and without gastroprotection, increasing the risk of gastrointestinal bleeding.To evaluate the effectiveness of a multicomponent intervention-clinician notification with nurse facilitation (CNNF)-in reducing high-risk use of antiplatelet medications in patients taking warfarin without a proton pump inhibitor (PPI).For patients in the CNNF group, nurses sent electronic messages to clinicians identifying patients with high-risk antiplatelet use, recommending consideration of either antiplatelet discontinuation or PPI initiation, and offering to facilitate any medication changes. The primary outcome was the percentage of patients who self-reported either discontinuing antiplatelet therapy or initiating a PPI at 7 to 10 weeks. The secondary outcome was the percentage of patients with a documented clinician recommendation to make such a medication change.Among 220 patients, CNNF was associated with increased odds of discontinuing antiplatelet therapy or initiating a PPI in the intention-to-treat analysis (adjusted odds ratio [aOR] 5.76, 95% CI 2.54, 13.05). The effect was stronger in a modified completer analysis (n = 126, aOR 43.6, 95% CI 6.56, 289.88). The intervention was also associated with increased odds of a clinician recommendation for a medication change (75/110 [68.2%] versus 1/110 [0.9%], log aOR 19.86, 95% CI 10.63, 29.09). Surgeons and proceduralists were less likely to recommend medication changes relative to other clinicians (log aOR -16.08, 95% CI -23.34, -8.82).The multicomponent intervention effectively led to antiplatelet discontinuation or PPI initiation in patients initially prescribed warfarin-antiplatelet therapy without gastroprotection.

Proton Pump Inhibitor Use Exceeding the U.S. Food and Drug Administration Approved Treatment Duration for Patients With Peptic Ulcer Disease: A Retrospective Cohort Study

BACKGROUND

Proton-pump inhibitors (PPIs) are effective in treating peptic ulcer disease (PUD), but they are often prescribed beyond the approved duration. Because PPIs are associated with adverse effects, there is a need for effective stewardship.

OBJECTIVE

To identify the frequency of and healthcare factors associated with PPI prescriptions exceeding the approved eight-week treatment duration for PUD.

METHODS

We conducted a retrospective cohort study of patients diagnosed with acute PUD without other indications for PPI use using data from the Veterans Health Administration in the United States. Exposures were patient, provider, and facility factors that could influence PPI prescribing. The outcome was time to a filled PPI prescription exceeding the approved treatment duration for PUD. Associations were assessed using a multivariable time-to-recurrent-event model to calculate adjusted hazard ratios (aHR) and population-attributable fractions. Patients who developed indications for long-term PPI use were censored.

RESULTS

We identified 7708 patients with PUD who met eligibility criteria and received PUD treatment (median age 79 [IQR 71-85], 7% female). Thirty-five percent had PPI prescriptions exceeding the approved duration for a median of 346 days (IQR 165-643) of overuse. On the patient level, inpatient PUD diagnosis (aHR 1.32, 95% CI 1.25-1.39), use of nonsteroidal anti-inflammatory drugs (NSAIDs) (aHR 1.26, 95% CI 1.18-1.34), use of anticoagulants (aHR 1.25, 95% CI 1.13-1.38), and moderate frailty (1.15, 95% CI 1.06-1.26) had the strongest associations with filled PPI prescriptions exceeding the approved duration. On the health-system level, inpatient PUD diagnosis had the highest peak population attributable fraction at 0.26, followed by NSAIDs and anticoagulants at 0.18.

CONCLUSIONS

Markers of patient complexity and medication use not meeting gastroprotection guidelines are associated with inappropriate PPI persistence among patients with PUD. These data may inform future targeted PPI deprescribing programs.

Prevalence of bleeding in patients on single or dual antiplatelet therapy combined with vitamin K antagonists or direct oral anticoagulants

BackgroundPatients with atrial fibrillation often require anticoagulation therapy to prevent stroke and thromboembolism. However, anticoagulants can have serious side effects, such as bleeding, particularly when combined with antiplatelet therapy.ObjectiveThe aim of this study is to estimate the prevalence of major bleeding in patients receiving either dual or triple antithrombotic therapy.MethodThis study is a single-center retrospective chart review utilizing the hospital electronic health record. The prevalence and percentage of bleeding events were reported for each antithrombotic regimen.ResultsOf the 539 patients receiving oral anticoagulants, 202 were using oral anticoagulants in combination with either single or dual antiplatelet therapy. Out of 35 patients using triple antithrombotic therapy, four (11.4%) experienced major bleeding. Based on the analysis of 73 patients using anticoagulants in combined with clopidogrel, the results showed that one patient (1.3%) suffered bleeding. Among the 94 patients treated with anticoagulants plus aspirin, seven (7.4%) experienced major bleeding events.ConclusionThe combination of anticoagulants and antiplatelet agents is associated with an elevated bleeding risk. Patients receiving triple antithrombotic therapy experience high prevalence of bleeding. Nonetheless, the group receiving anticoagulant and clopidogrel alone exhibited low prevalence of bleeding risk.

Post-discharge pharmacotherapy in people with atrial fibrillation hospitalized for acute myocardial infarction: an Australian cohort study 2018-22

BACKGROUND

Dual antiplatelet therapy with P2Y12 inhibitors (P2Y12i) and aspirin following acute myocardial infarction (AMI) prevents future ischaemic events. People with atrial fibrillation (AF) also require oral anticoagulants (OAC), increasing bleeding risk. Guidelines recommend post-discharge prescribing of direct OAC with clopidogrel and discontinuation of P2Y12i after 12 months, but little is known about use in clinical practice.

AIM

To describe post-discharge use of OACs and P2Y12i in people with AF and a history of OAC use hospitalized for AMI.

METHODS AND RESULTS

We identified 1330 people hospitalized for AMI with a diagnosis of AF and history of OAC use in New South Wales, Australia, July 2018-June 2020. We identified three aspects of post-discharge antithrombotic medicine use with possible safety implications: (1) not being dispensed OACs; (2) dispensing OAC and P2Y12i combinations associated with increased bleeding (involving warfarin, ticagrelor, or prasugrel); and (3) P2Y12i use longer than 12 months.After discharge, 74.3% of people were dispensed an OAC, 45.4% were dispensed a P2Y12i, and 35.8% were dispensed both. People with comorbid heart failure or cancer were less likely to receive OACs. Only 11.2% of people who dispensed both an OAC and P2Y12i received combinations associated with increased bleeding; this was more common among people with chronic kidney disease or prior warfarin or statin use. A total of 44.6% of people dispensed both medicines continued P2Y12i for over 12 months; this was more common in people who received a revascularization or lived in areas of social disadvantage.

CONCLUSION

We identified potential gaps in pharmacotherapy, including underuse of recommended therapies at discharge, use of combinations associated with increased bleeding, and P2Y12i use beyond 12 months. Prescribing vigilance across both hospital and community care is required.

Impact of the addition of clinical pharmacy services to the cardiac catheterization laboratory

PURPOSE

Our cardiology pharmacy team recently expanded services to the cardiac catheterization laboratory (CCL) with the addition of a dedicated pharmacist; since that time, numerous process improvement initiatives have been implemented and medication review has been expanded.

METHODS

We conducted a single-center retrospective chart review. The primary outcome was the percentage of patients discharged from the CCL on appropriate guideline-directed medical therapy components after percutaneous coronary intervention (PCI) before and after integration of dedicated pharmacist services in the CCL. Secondary outcomes were assessed for all patients discharged from the CCL after implementation of a pharmacy presence and included the total number of pharmacist interventions at discharge, the number of prescriptions directed to our outpatient pharmacy, the number of medication reconciliations performed, the number of "protect your stent" educational sessions completed, and the number of clinically significant pharmacist interventions to the medication regimens of patients who underwent PCI.

RESULTS

After a dedicated pharmacist was integrated to review CCL discharges, significantly more patients were discharged on high-intensity statin therapy (47.9% vs 78.0%; P < 0.0001) and fewer patients were discharged on omeprazole or esomeprazole prescribed concurrently with clopidogrel (18.7% vs 3.9%; P < 0.0001) following PCI. Of the patients who underwent PCI after addition of the pharmacist (n = 259), 23.9% (n = 66) had a clinically significant pharmacist intervention at discharge and 96.5% (n = 250) received protect your stent education. Of all discharges following pharmacist integration (n = 3,501), 13.6% (n = 477) had at least one pharmacist intervention, 771 prescriptions were sent to our outpatient pharmacy, and 66.4% (n = 2,325) of patients had a medication reconciliation completed.

CONCLUSION

Addition of a dedicated pharmacist to the CCL was associated with increased rates of high-intensity statin prescribing and decreased use of esomeprazole and omeprazole with clopidogrel.

Procedural and Antithrombotic Therapy Optimization in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Narrative Review

In the past decades, percutaneous coronary intervention (PCI) has become the most common modality for myocardial revascularization in patients with coronary artery disease (CAD). Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is essential in all patients undergoing PCI to prevent thrombotic complications. A large proportion of patients undergoing PCI also have concomitant atrial fibrillation (AF), thus requiring an oral anticoagulant (OAC) to prevent ischemic stroke or systemic embolism. However, the association between OAC and DAPT further increases the risk of bleeding. Compared with a triple antithrombotic therapy (TAT), dual antithrombotic therapy (DAT) has shown to reduce bleeding events, but at the cost of higher risk of stent thrombosis. In this field, patients with AF undergoing PCI represent a special population with significant challenges, and several strategies are needed to reduce the risk for bleeding complications. In this review, we will discuss both the procedural and antithrombotic strategies to optimize ischemic and bleeding outcomes in patients with AF undergoing PCI.

Intersections and Challenges in the Management of Acute Coronary Syndrome and Stroke: Pathophysiology, Treatment Dilemmas, and Integrated Prevention Strategies

Acute coronary syndrome (ACS) and stroke are interconnected conditions that often share risk factors such as atherosclerosis, thrombosis, and systemic inflammation. When these events occur simultaneously, they present unique diagnostic and therapeutic challenges. This review explores the pathophysiological mechanisms linking ACS and stroke, including common pathways like plaque instability, cardioembolism, and endothelial dysfunction, while highlighting the distinct features of ischemic and hemorrhagic strokes. The manuscript provides an overview of diagnostic strategies, emphasizing the role of biomarkers, advanced neuroimaging, and risk stratification tools in guiding acute management. Furthermore, the review delves into treatment approach, emphasizing the need to balance reperfusion therapies for ACS with thrombolysis or thrombectomy for ischemic stroke while carefully managing the challenges posed by anticoagulation in cases complicated by bleeding. Long-term strategies for secondary prevention are examined, including antithrombotic regimens tailored to the dual risk of thrombosis and bleeding, as well as lipid-lowering and blood pressure management. Future perspectives highlight the potential of novel pharmacological agents, neuroprotective therapies, and AI-driven tools to enhance patient outcomes. This review underscores the importance of integrated, multidisciplinary care and identifies key areas for future research to optimize the management of these high-risk patients.

Hemorrhage risk associated with triple antithrombotic therapy: a focused real-world pharmacovigilance disproportional analysis study

BACKGROUND

Triple antithrombotic therapy (TAT), combining dual antiplatelet therapy (DAPT) with oral anticoagulants, is commonly used in patients requiring long-term anticoagulation following acute coronary syndrome or percutaneous coronary intervention. However, TAT may increase the risk of hemorrhage. There is a dearth of data regarding the risks of bleeding with various oral anticoagulants in TAT in comparison with DAPT and individual anticoagulants and antiplatelets due to which we carried out the present study examining the real-world pharmacovigilance data.

METHODS

Data were extracted from the USFDA Adverse Event Reporting System (AERS) from March 2004 to June 2024 using the Standardized MedDRA Query (SMQ) code for "haemorrhages." We employed the "case-non-case" approach in disproportionality analysis to detect safety signals for hemorrhage among anticoagulant, antiplatelet, dual antiplatelet and triple antithrombotic combinations. Reports including combinations of DAPT (acetylsalicylic acid and clopidogrel) with oral anticoagulants (acenocoumarol, apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin) were analyzed. Signal detection used both frequentist (reporting odds ratio [ROR], proportional reporting ratio and Bayesian (Bayesian Confidence Propagation Neural Network, Multi-Item Gamma Poisson Shrinker algorithms. The lower limit of 95% confidence interval of ROR above 1 indicates higher reporting risk of bleeding. Following outcomes were evaluated for each TAT: death, disability and hospitalization.

RESULTS

Of 20,626 unique reports, 812 involved TAT, 3,820 DAPT, and 15,995 individual antiplatelets. Most cases occurred in elderly patients (age ≥ 65 years) with a predominance of male patients. Rivaroxaban combined with DAPT presented the highest hemorrhage signal (ROR: 82.84; 95% CI, 60.77-112.92), while apixaban showed the lowest (ROR: 13.11; 95% CI, 9.39-18.3) and the other anticoagulants are as follows: warfarin (ROR: 15.96; 95% CI: 18.36), dabigatran (ROR: 27.32; 95% CI: 20.03-37.26) and acenocoumarol (ROR: 43.98; 95% CI: 17.21-112.4). Mortality and hospitalization rates varied significantly among treatments, with rivaroxaban linked to the highest mortality.

CONCLUSION

This study highlights the elevated hemorrhage risk associated with TAT, particularly with rivaroxaban, while apixaban appears safer in terms of bleeding and mortality. These findings underscore the need for cautious monitoring of bleeding outcomes with anticoagulant regimens, particularly rivaroxaban combinations for optimizing patient outcomes. However, the signals obtained in this study need to be validated in future trials.

Comparison of Risk-Scoring Models to Predict Gastrointestinal Bleeding in Patients With Direct Oral Anticoagulants

BACKGROUND AND AIM

The risk of gastrointestinal bleeding (GIB) remains a concern with the use of direct oral anticoagulants (DOAC). We evaluated the efficacy of four risk-scoring models (HAS-BLED, ATRIA, VTE-BLEED, and ORBIT) in predicting GIB according to the concomitant use of antiplatelet therapy in DOAC users.

METHODS

Patients prescribed DOAC between December 2014 and October 2020 were enrolled in two university-affiliated hospitals. The performance of the four models was compared based on the concomitant use of antiplatelet therapy. The primary outcomes were likelihood ratios and the area under the receiver operating characteristic (AUROC) curve to predict GIB.

RESULTS

A total of 4494 patients were included in the study. The AUROC values for the entire cohort were 0.643 (95% CI: 0.601-0.686) for HAS-BLED, 0.693 (95% CI: 0.649-0.737) for ATRIA, 0.708 (95% CI: 0.665-0.750) for VTE-BLEED, and 0.709 (95% CI: 0.667-0.751) for ORBIT. The AUROC for all scoring models increased in patients without antiplatelet therapy compared to the entire cohort and patients with antiplatelet therapy. The specificity and diagnostic accuracy for all scoring models increased in patients without antiplatelet therapy compared to patients with antiplatelet.

CONCLUSIONS

Our results confirmed that current risk-scoring models for predicting GIB perform better in patients without antiplatelet therapy than in those on concomitant antiplatelet therapy. This suggests that future risk prediction models should consider the concomitant use of antiplatelet therapy for diagnostic accuracy.

The Complexities of Managing Acute Coronary Syndrome in a Patient With Hereditary Hemorrhagic Telangiectasia: A Case Report and Literature Review

Hereditary hemorrhagic telangiectasia (HHT) is an uncommon autosomal dominant genetic disorder characterized by mucocutaneous and gastrointestinal telangiectasias and visceral arteriovenous malformations (AVMs). Patients with HHT have an increased risk of both bleeding and arterial and venous thrombosis. Due to the increased risk of bleeding, these patients generally cannot tolerate antiplatelet or anticoagulant therapies. This poses a particular hurdle when treating acute coronary syndrome (ACS). Our case involves a 79-year-old male patient with a past medical history of HHT, major gastrointestinal bleeding (GIB), and coronary artery disease who presented with a non-ST-segment elevation myocardial infarction (NSTEMI) and acute-on-chronic anemia. Our treatment options were limited given his intolerance to antiplatelet and anticoagulant therapies which resulted in major GIB, making him a poor candidate for percutaneous coronary intervention. We consulted cardiology and treated him with beta-blockers to decrease oxygen demand, packed red blood cell (PRBC) transfusion to increase oxygen supply, and ranolazine for symptom relief. His symptoms improved and he was discharged. Four weeks later, he suffered a cardiac arrest due to ventricular fibrillation. His family chose to pursue comfort measures, and he was transferred to an inpatient hospice. By reporting this case, we aim to highlight the unique challenges faced when managing ACS in patients with HHT. We underscore the importance of mitigating the risks of coronary artery disease in these patients. Given the limited treatment options and low tolerance to treatment modalities used for ACS, early detection of HHT and implementing effective primary prevention strategies are crucial in these patients.

Safety and efficacy of edoxaban monotherapy after bioabsorbable polymer everolimus-eluting stent implantation in a human-like coronary atherosclerotic porcine model

Background

The combination of antiplatelet and antithrombotic drugs increases the risk of bleeding in patients with atrial fibrillation after coronary drug-eluting stent (DES) implantation. However, the appropriateness of direct-acting oral anticoagulant (DOAC) monotherapy at the time of stent implantation remains uncertain. The objective of this study was to evaluate the safety and efficacy of DOAC monotherapy, specifically using factor Xa inhibitors such as edoxaban, in a low-density lipoprotein receptor knockout (LDL-R-/-) miniature pig model of human-like unstable coronary plaques compared to conventional dual-antiplatelet therapy (DAPT).

Methods

We evaluated the safety and efficacy of edoxaban monotherapy in the LDL-R-/- pig model with human-like unstable coronary plaques induced by a high-cholesterol, high-fat diet. Animals underwent DES implantation, followed by four weeks of treatment with either edoxaban monotherapy (3 mg/kg/day) or the DAPT regimen (aspirin 100 mg/day and clopidogrel 75 mg/day). Outcomes were assessed by optical coherence tomography (OCT), virtual histology intravascular ultrasound (iMap-IVUS), and histology. Key endpoints included in-stent thrombus formation, neointimal thickness, and coronary plaque composition.

Results

Edoxaban monotherapy demonstrated a significantly thinner neointimal layer (120.0 [92.5-160.0] μm vs. 210.0 [180.0-240.0] μm, p < 0.001) and smaller neointimal area (1.06 [0.82-1.46] mm2 vs. 1.84 [1.61-2.24] mm2, p < 0.001) compared to DAPT. Neointimal coverage, fibrin deposition, and inflammatory cell infiltration were comparable between groups. No in-stent thrombi were observed in either group. iMap-IVUS findings indicated that edoxaban monotherapy significantly suppressed the increase in lipidic and necrotic plaque area while promoting fibrotic area expansion.

Conclusions

Edoxaban monotherapy demonstrated superior efficacy in suppressing neointimal hyperplasia and stabilizing coronary plaques compared to DAPT with equivalent safety in preventing in-stent thrombus formation. These results provide important preclinical evidence supporting the potential of DOAC monotherapy as an antithrombotic strategy after DES implantation and warrant further investigation in clinical trials.

Oral anticoagulant (OAC) monotherapy vs. dual-antithrombotic therapy (DAT) in patients with atrial fibrillation and coronary artery disease; a meta-analysis of four randomized controlled trials

Background

Dual-antithrombotic therapy (DAT) is recommended for patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) but carries an increased risk of bleeding. Recent trials suggest oral anticoagulant (OAC) monotherapy as a safer alternative, but data remains limited. We conducted a meta-analysis to compare OAC monotherapy with DAT in this population.

Methods

A comprehensive literature search was conducted using PubMed, Embase, and Cochrane Central Library to identify randomized controlled trials (RCTs) that compared OAC monotherapy with DAT in patients with AF and stable CAD. A bivariate random-effects model was used to perform meta-analyses. Statistical analyses were conducted using R Software 4.4.1, with a significance level of P < 0.05. Heterogeneity was assessed using I 2 statistics, and the quality of studies was evaluated using the revised Cochrane risk-of-bias tool.

Results

Four RCTs with a total of 4123 patients (20.2% females) were included. The mean age of the participants was 74 years. The results showed a significant reduction in major or clinically relevant nonmajor bleeding (risk ratio [RR]: 0.52; 95% confidence interval [CI]: 0.34-0.80; P = 0.003) in the OAC monotherapy group compared to the DAT group. However, net adverse clinical events (NACE) (RR: 0.67; 95% CI: 0.45-1.01; P = 0.054), major ischemic events (RR: 0.98; 95% CI: 0.62-1.53; P = 0.91) and all-cause mortality (RR: 0.94; 95% CI: 0.49-1.83; P = 0.87) were comparable between the two groups.

Conclusions

In patients with AF and stable CAD, OAC monotherapy reduced the risk of major bleeding, with no significant differences in NACE, major ischemic events, or all-cause mortality as compared to DAT.

Antiplatelets for Cardiovascular Disease in Non-valvular AF with Rivaroxaban: A Subanalysis of the EXPAND Study

AIM

In this subanalysis of the EXPAND study, we evaluated the risks and benefits of rivaroxaban plus antiplatelet therapy (APT) for patients with non-valvular atrial fibrillation (NVAF) complicated by stable coronary artery disease (CAD), ischemic stroke, or peripheral artery disease (PAD).

METHODS

From the EXPAND study population (n=7,141), patients with NVAF complicated by stable CAD (n=886), ischemic stroke (n=1,231), or PAD (n=160) were included. Patients complicated by any of them were set as ALL (n=2,030). Patients were all treated with rivaroxaban (10 or 15 mg/day) with (+) or without (-) APT. Efficacy outcomes were symptomatic stroke＋systemic embolism (SE), symptomatic stroke＋SE＋myocardial infarction＋cardiovascular death, and all-cause death. Safety outcomes included major and any bleeding. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for differences between the APT(+) and APT(-) groups.

RESULTS

There were no significant differences in the efficacy outcomes between the APT(+) and APT(-) groups in the ALL cohort or in the CAD and STROKE sub-cohorts. In the PAD subcohort, the HR [95% CI] for all-cause death in the APT(+) group increased (4.43 [1.05-18.71]; p=0.043). In the APT(+) group, the HR [95% CI] for any bleeding increased in the ALL cohort (1.28 [1.01-1.62]; p=0.044) and STROKE subcohort (1.42 [1.01-2.01]; p=0.047), and for major bleeding in the CAD subcohort (2.00 [1.01-3.93]; p=0.046).

CONCLUSIONS

Rivaroxaban with APT did not reduce ischemic outcomes in patients with stable CAD or ischemic stroke; however, it did increase the risk of bleeding in patients with stable CAD or ischemic stroke.

Association of aspirin use with risk of intracerebral hemorrhage in patients without history of stroke or transient ischemic attack in the UK Biobank

BACKGROUND

The association between aspirin use and the risk of intracerebral hemorrhage (ICH) among individuals without previous stroke events is inconclusive.

AIM

We investigated the association between regular aspirin use and ICH risk in middle-aged and older adults without previous stroke or transient ischemic attack (TIA).

METHODS

This prospective population-based study included participants older than 40 years with no history of stroke or TIA from the UK Biobank. The main exposure was regular aspirin use. Cox regression analyses and propensity score matching analyses estimated the hazard ratios (HRs) for aspirin use for incident fatal and non-fatal ICH. We conducted pre-specified subgroup analyses for selecting individuals at high risk of ICH when using aspirin. Multiple sensitivity analyses were performed to test the robustness of our results.

RESULTS

A total of 449,325 participants were included into final analyses (median (IQR) age 58 (50-63) years, 54.6% females), of whom 58,045 reported aspirin use. During a median follow-up of 12.75 (IQR: 12.03-13.47) years, 1557 (0.3%) incident ICH cases were identified, of which 399 (25.6%) were fatal. Aspirin was not associated with increased risk of overall (hazard ratio (HR): 1.11, 95% confidence interval (CI): 0.95-1.27, P = 0.188), fatal (HR: 1.03, 95% CI: 0.78-1.36, P = 0.846) and non-fatal (HR: 1.12, 95% CI: 0.95-1.33, P = 0.186) ICH. Propensity score matching analysis showed similar results. Subgroup analysis indicated that aspirin use in individuals older than 65 years or with concurrent anticoagulant use was correlated with increased risk of ICH.

CONCLUSION

In this large cohort study of middle-aged and older adults without stroke or TIA events, there was no significant association between aspirin use and ICH risk in the real-world setting. However, it is possible that aspirin use in those aged over 65 years and concurrent anticoagulant treatment may increase the risk of ICH.

Ultrasound-guided kidney biopsy: a ten-year retrospective single-center experience and the promising role of clinical hypnosis

This retrospective analysis investigates the outcomes and complications of 682 kidney biopsies performed at ARNAS G. Brotzu from 2010 to 2021. Our findings indicate a minor complication rate of 9.1%, with severe complications being exceedingly rare at 0.3%. Age did not contribute to an increased risk, underscoring the procedure's safety across age groups. Clinical hypnosis was incorporated into the biopsy protocol in a subset of patients (n = 45) from April 2019 to December 2023. Over 90% of these patients reported no perception of the procedure, and 60% experienced no pain. According to STAY-Y test scores, this approach significantly reduced anxiety post-procedure (p = 0.001); no major or minor complications were observed in this group. While our study reaffirms the very low risk of severe complications in kidney biopsies, it also highlights the potential benefits of adjunct clinical hypnosis in enhancing patient comfort and cooperation during the procedure. This exploration opens a promising avenue for further investigation to improve patient experiences and procedural outcomes in kidney biopsies.

Atrial Fibrillation: A Review

Importance

In the US, approximately 10.55 million adults have atrial fibrillation (AF). AF is associated with significantly increased risk of stroke, heart failure, myocardial infarction, dementia, chronic kidney disease, and mortality.

Observations

Symptoms of AF include palpitations, dyspnea, chest pain, presyncope, exertional intolerance, and fatigue, although approximately 10% to 40% of people with AF are asymptomatic. AF can be detected incidentally during clinical encounters, with wearable devices, or through interrogation of cardiac implanted electronic devices. In patients presenting with ischemic stroke without diagnosed AF, an implantable loop recorder (ie, subcutaneous telemetry device) can evaluate patients for intermittent AF. The 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) Guideline writing group proposed 4 stages of AF evolution: stage 1, at risk, defined as patients with AF-associated risk factors (eg, obesity, hypertension); stage 2, pre-AF, signs of atrial pathology on electrocardiogram or imaging without AF; stage 3, the presence of paroxysmal (recurrent AF episodes lasting ≤7 days) or persistent (continuous AF episode lasting >7 days) AF subtypes; and stage 4, permanent AF. Lifestyle and risk factor modification, including weight loss and exercise, to prevent AF onset, recurrence, and complications are recommended for all stages. In patients with estimated risk of stroke and thromboembolic events of 2% or greater per year, anticoagulation with a vitamin K antagonist or direct oral anticoagulant reduces stroke risk by 60% to 80% compared with placebo. In most patients, a direct oral anticoagulant, such as apixaban, rivaroxaban, or edoxaban, is recommended over warfarin because of lower bleeding risks. Compared with anticoagulation, aspirin is associated with poorer efficacy and is not recommended for stroke prevention. Early rhythm control with antiarrhythmic drugs or catheter ablation to restore and maintain sinus rhythm is recommended by the 2023 ACC/AHA/ACCP/HRS Guideline for some patients with AF. Catheter ablation is first-line therapy in patients with symptomatic paroxysmal AF to improve symptoms and slow progression to persistent AF. Catheter ablation is also recommended for patients with AF who have heart failure with reduced ejection fraction (HFrEF) to improve quality of life, left ventricular systolic function, and cardiovascular outcomes, such as rates of mortality and heart failure hospitalization.

Conclusions and Relevance

AF is associated with increased rates of stroke, heart failure, and mortality. Lifestyle and risk factor modification are recommended to prevent AF onset, recurrence, and complications, and oral anticoagulants are recommended for those with an estimated risk of stroke or thromboembolic events of 2% or greater per year. Early rhythm control using antiarrhythmic drugs or catheter ablation is recommended in select patients with AF experiencing symptomatic paroxysmal AF or HFrEF.

Impact of Underdosing of Direct Oral Anticoagulants on Clinical Outcomes in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

BACKGROUND

Underdoses of direct oral anticoagulants (DOAC) are sometimes prescribed due to bleeding risk concerns in patients with atrial fibrillation (AF). We investigated the prevalence of DOAC underdosing and its impact on clinical outcomes in AF patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

This multicenter observational cohort study enrolled patients with AF on DOAC undergoing PCI between January 2015 and March 2021 at 15 institutions across Japan. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE), all-cause mortality, ischemic stroke, and major bleeding events, were evaluated. Of 623 patients enrolled, 167 (26.8%) received underdoses, 224 (36.0%) received appropriate low doses, 210 (33.7%) received appropriate standard doses, and 22 (3.5%) received overdoses. Clinical outcomes were compared between patients with underdoses (n=167) and appropriate doses (n=434). Although the incidence of MACE, all-cause mortality, and major bleeding events did not differ significantly between the 2 groups (log-rank P=0.850, P=0.163, and P=0.711, respectively), ischemic stroke occurred more frequently in the underdose than appropriate-dose group (log-rank P=0.011). After propensity score matching, the same result was observed for the frequency of ischemic stroke (log-rank P=0.026).

CONCLUSIONS

Compared with appropriate doses of DOAC, DOAC underdosing was associated with a higher incidence of ischemic stroke, despite no significant difference in MACE, all-cause mortality, and major bleeding events in AF patients undergoing PCI.

ANti-Thrombotic strAtegy for the management of nonocclusive thRombus with ST-segment elevation myocardial infarCtion in young pAtients - ANTARTICA study

INTRODUCTION

Various cardiovascular thrombo-embolic clinical entities use combined ATS for prevention and treatment. After PCI, AF patients are typically prescribed DOAC, DAPT/SAPT, as component of ATS to minimize stroke risk and treat pulmonary embolism and venous thromboembolism. Some small observational studies have shown that a combined ATS can clear small thrombi in LV dysfunction and/or apical aneurysms. Therefore, we present a practical, cost-effective, and proof-of-concept ATS for non-occlusive significant coronary thrombus in young, clinically stable STEMI patients based on the aforementioned experiences.

METHODS

We retrospectively reviewed 145 stable STEMI cases with nonocclusive thrombus and thrombolysis in myocardial infarction flow 2/3 who received dabigatran and clopidogrel (ATS arm). They were compared to 147 comparable patients who received standard-of-care PCI (Control arm). At presentation and 6-months after ATS, NYHA functional class and LVEF were measured in all subjects. All the patients in the ATS arm underwent CT-CAG at 6-months. We examined significant safety outcomes like hemorrhage, reinfarction, and cardiac mortality.

RESULTS

The primary angiographic outcome demonstrated complete resolution of the thrombus in all the cases of ATS arm. In the ATS arm, the clinical secondary outcome showed a greater improvement in NYHA class, from 3.53 to 1.07, compared to the control group's 3.6 to 1.49 (p = 0.013). Also, the secondary echocardiographic outcome demonstrated a significant improvement in LVEF from a mean of 45.1 %-49.2 % in the ATS arm vs. 44.0 %-44.9 % in the control arm (p < 0.001). Clinical safety indicated TIMI bleeding and reinfarction reductions. There was no mortality in either arm.

CONCLUSION

Delaying PCI and treating STEMI patients with antithrombotic drugs reduced no-reflow, distal embolization, and intraprocedural thrombotic events. The medical intervention improved myocardial preservation alone.

Good clinical practice recommendations for proton pump inhibitor prescription and deprescription. A review by experts from the AMG

INTRODUCTION AND AIM

Proton pump inhibitors (PPIs) are widely known drugs that are used quite frequently and indicated in both the short and long terms, in numerous acid-related diseases. Our aim was to produce an expert review that establishes recommendations for the adequate prescription and deprescription of PPIs.

METHODS

A group of experts in PPI use that are members of the Asociación Mexicana de Gastroenterología (AMG), after extensively reviewing the published literature and discussing each recommendation at a face-to-face meeting, prepared the present document of good clinical practice recommendations. This document is not intended to be a clinical practice guideline or utilize the methodology said format requires.

RESULTS

Eighteen experts on PPI use developed 22 good clinical practice recommendations for prescribing short-term, long-term, and on-demand PPIs, recognizing adverse events, and lastly, deprescribing PPIs, in acid-related diseases.

CONCLUSIONS

At present, there is scientific evidence on PPI use in numerous diseases, some in the short term (4-8 weeks), others on-demand (for short periods until symptoms improve), or in the long term (without suspending). Numerous adverse effects have been attributed to PPIs, but the majority have no well-established causal association. Nevertheless, PPIs should be suspended when there is no clear indication for their use. These recommendations aim to aid general physicians and specialists, with respect to PPI prescription and deprescription.

Dual Antiplatelet and Anticoagulation Regimens for Women Undergoing Percutaneous Coronary Intervention

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention is necessary for preventing stent thrombosis and ensuring long-term cardiovascular protection. It is important to be thoughtful in balancing thrombotic and bleeding risk when deciding therapy regimen and duration. Revascularization randomized trials have studied many specific, at-risk populations; however, women remain underrepresented. Although there is evidence to support shortened DAPT duration in women, especially those at higher bleeding risk or on chronic oral anticoagulation, we need trials specifically enrolling and focusing on women.

Patient Management Following Percutaneous Coronary Intervention

Percutaneous coronary intervention (PCI) is a mainstay procedure for the treatment of coronary artery disease. PCI techniques have evolved considerably since the advent of PCI in 1978, and with this evolution in techniques has come changes in the best practices for patient management following PCI. The objective of this review is to provide a comprehensive overview of key considerations in patient management following PCI. The long-term management of patients post-PCI should follow 3 main principles: 1) lifestyle modification and reduction of risk factors; 2) implementation of secondary prevention therapies; and 3) timely detection of restenosis. Best practices in achieving these principles include promotion of smoking cessation, regular physical activity, and a healthy diet, as well as blood pressure, diabetes mellitus, lipid, and weight management; prescription of secondary prevention therapies balancing ischemic and bleeding risk; and avoidance of routine surveillance for restenosis.

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.

Protective effects of long term antiplatelet and anticoagulant therapy in hospitalized patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD), with its rising prevalence rates is associated with an increased risk of cardiovascular and thromboembolic events. Antiplatelets and/or anticoagulants agents are often prescribed but the literature on the impact of long-term anticoagulation and/or antiplatelet use among patients hospitalized with IBD is scarce. The aim of this study is to assess the outcomes of patients hospitalized with IBD on antiplatelet and/or anticoagulant agents.

AIM

To investigate the effects of long-term use of antiplatelets/anticoagulants on clinical outcomes in patients hospitalized with IBD.

METHODS

We conducted a retrospective cohort study using the Nationwide Inpatient Sample database, including all adult IBD patients hospitalized in the United States from 2016 to 2019. Patient cohorts were stratified based on antiplatelet/anticoagulant therapy status. Multivariate regression analysis was done to assess outcomes, adjusting for potential confounders. The primary outcome was mortality, whereas length of stay (LOS), total parenteral nutrition, acute kidney injury, sepsis, shock, gastrointestinal bleeding, need for colonoscopy/sigmoidoscopy, abdominal surgery and total hospitalization charges were secondary outcomes.

RESULTS

Among 374744 hospitalized IBD patients, antiplatelet or anticoagulant therapy alone was associated with significantly lower in-hospital mortality and reduced healthcare utilization, including shorter LOS and decreased hospitalization costs. Combined therapy was associated with a protective effect on mortality, but did not reach statistical significance. Notably, therapy did not exacerbate disease severity or complications, although higher odds of gastrointestinal bleeding were observed.

CONCLUSION

Our study highlights the potential benefits of long-term anticoagulation/antiplatelet therapy in hospitalized IBD patients, with improved mortality outcomes and healthcare utilization. While concerns regarding gastrointestinal bleeding exist, the overall safety profile suggests a role for these agents in mitigating thromboembolic risks without exacerbating disease severity. Further research is needed to look at optimal treatment strategies and addressing limitations to guide clinical decision-making in this population.

Prophylactic Proton Pump Inhibitors in Upper Gastrointestinal Bleeding: Impact and Underprescription in a French Multicentric Cohort

BACKGROUND

Appropriate prescription of Proton pump inhibitors (PPIs) remains an important concern amid the rising overuse. A gap exists in the literature regarding the benefit of PPI prophylaxis and the consequences of underprescription in patients at risk for upper gastrointestinal bleeding (UGIB).

AIMS

This study aims to describe the characteristics of hemorrhage in relation to PPI use in patients experiencing UGIB, with a focus on high-risk individuals requiring gastroprotection.

METHODS

Data from a French multicentric cohort of patients experiencing UGIB were analyzed. Patients using PPI were compared to those without PPI considering bleeding etiologies and outcomes of peptic ulcer disease (PUD)-related hemorrhage. The rate of PPI use and its effect on bleeding characteristics in high-risk populations, defined based on international guidelines, were also assessed.

RESULTS

Among 2497 included patients, 31.1% were on PPI at bleeding onset. PPI users exhibited a significantly lower rate of PUD-related bleeding in comparison with those without PPI (24.7 vs 40.8%, respectively, p < 0.0001). Similar difference was observed in high-risk populations, of whom, only 40.3% had gastroprotection with PPI before bleeding onset. PPI prophylaxis, however, did not influence the severity of bleeding in the general study population or in high-risk groups. Multivariate analysis identified age, comorbidities, and having more than two anti-thrombotic agents as predictors of severe bleeding.

CONCLUSIONS

PPI users appear to have a lower rate of bleeding ulcers compared to non-users. However, underprescription in high-risk groups raises the need for standardized care to ensure appropriate PPI use.

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.

Comparison between mono vs dual vs triple antiplatelet therapy in patients with ischemic heart disease undergoing PCI, a network meta-analysis

AIMS

We aim to research the efficacy and safety of single(SAPT), dual(DAPT), and triple(TAPT) antiplatelets approaches across IHD patients undergoing PCI.

METHODS AND RESULTS

A network meta-analysis was conducted until April 1st, 2024, using the netmeta package in R studio 4.3.3. Primary outcomes were cardiac death, myocardial infarction(MI), stent thrombosis, stroke, and major bleeding(BARC 3-5). From 25 studies, a total of 65115 patients were included. For cardiac death, TAPT had no different risk than DAPT compared to SAPT [RR = 0.74; 95%CI (0.40 to 1.35); p-value = 0.33], [RR = 1.01, 95%CI (0.84 to 1.19); p-value = 0.87] respectively. For MI, TAPT had no different risk than DAPT compared to SAPT [RR = 0.77; 95%CI (0.51 to 1.16); p-value = 0.2047], [RR = 0.81, 95%CI (0.64 to 1.03); p-value = 0.0850] respectively. For stent thrombosis, DAPT had no different risk than TAPT compared to SAPT [RR = 0.74; 95%CI (0.45 to 1.21); p-value = 0.2284], [RR = 0.84, 95%CI (0.27 to 2.59); p-value = 0.7630] respectively. For stroke, DAPT had no different risk than TAPT in comparison to SAPT [RR = 0.91; 95%CI (0.75 to 1.10); p-value = 0.3209], and [RR = 0.87, 95%CI (0.43 to 1.76); p-value=0.6937], respectively. For Major bleeding(BARC 3-5), DAPT and TAPT increased major bleeding compared to SAPT, with only DAPT showing statistical significance. [RR = 1.43; 95%CI (1.09 to 1.88); p-value = 0.0107], and [RR = 2.78, 95%CI (0.90 to 4.78); p-value = 0.0852], respectively.

CONCLUSION

DAPT and TAPT increased the risk of bleeding events compared to SAPT. However, we found no significant differences between these regimens for the other primary outcomes.

Proton pump inhibitors and cardiovascular risk: a critical review

Proton pump inhibitors (PPI) are widely used medications for gastrointestinal disorders. Recent research suggests a potential association between long-term PPI use and increased cardiovascular (CV) risk, creating a complex clinical dilemma. This review critically evaluates the current evidence for this association, considering the limitations of observational studies and the lack of definitive confirmation from randomized controlled trials.This review delves into the reported association between PPIs and adverse CV events, examining proposed mechanisms such as drug interactions, electrolyte imbalances induced by PPIs and their potential impact on cardiac and vascular function. Evidence suggests these mechanisms converge, with varying influence depending on patient populations.Clinicians require a risk-benefit analysis for each patient considering their CV risk profile. Alternative gastrointestinal therapies should be explored for high-bleeding risk patients. Medications with lower cytochrome-P450 interaction potential may be preferable among essential PPI users. Elucidating the specific mechanisms by which PPIs might influence CV health, assessing long-term vascular effects and investigating interactions with newer anticoagulant medications are crucial for future research.

Development and Validation of Prognostic Models for Bleeding and Ischemia in Elderly Patients With Comorbid Acute Coronary Syndrome and Atrial Fibrillation

BACKGROUND

Acute coronary syndrome and atrial fibrillation are common cardiovascular diseases in elderly individuals. Patients with comorbidities face increased risks of bleeding and ischemia; however, there is a lack of prognostic models for quantifying these risks in this special population.

METHODS AND RESULTS

In this retrospective cohort study, 1851 patients (≥65 years old) with acute coronary syndrome and atrial fibrillation from 2 hospitals in China were included in the development cohort (1252 individuals) and 2 external validation cohorts (284 and 315 individuals). During 1-year follow-up, 96 Bleeding Academic Research Consortium type 3 or 5 bleeding events and 245 thromboembolic events were observed. In the development cohort, the concordance indexes for bleeding at 3, 6, and 12 mo ranged from 0.737 to 0.845 and for ischemia ranged from 0.723 to 0.777. The calibration curve and decision curve analysis indicated adequate calibration and clinical practicability. The concordance indexes varied from 0.679 to 0.809 in the validation cohorts. Subgroup analyses focusing on anticoagulant drugs and antithrombotic therapy were conducted, revealing similar discrimination and calibration. Kaplan-Meier curves demonstrated significant differences (log-rank P<0.001). Additionally, the models outperformed conventional models in concordance indexes, integrated discrimination improvement, and net reclassification improvement.

CONCLUSIONS

Our study provides 2 robust prognostic models with easily available clinical factors for predicting bleeding and ischemia in elderly patients with acute coronary syndrome and atrial fibrillation. Furthermore, we provide online calculators to facilitate individualized risk evaluation and clinical decision-making.

REGISTRATION

URL: www.chictr.org.cn/. Unique Identifier: ChiCTR2200067185.

Key targets of signal transduction neural mechanisms in acupuncture treatment of cardiovascular diseases: Hypothalamus and autonomic nervous system

Background

Cardiovascular disease is the leading cause of death worldwide. As a traditional Chinese treatment method, acupuncture has a unique role in restoring the balance of the human body environment. Due to its safety, non-invasive nature, and effectiveness in treating cardiovascular diseases, acupuncture has been widely welcomed and recognized among the world. A large amount of evidence shows that acupuncture can effectively regulate cardiovascular diseases through the autonomic nervous system. The hypothalamus, as an important component of regulating the autonomic nervous system, plays an important role in regulating the internal environment, maintaining homeostasis, and preserving physiological balance. However, there is currently a scarcity of review articles on acupuncture signal transduction and acupuncture improving cardiovascular disease through the hypothalamus and autonomic nervous system.

Objective

This review delves into the transduction of acupuncture signals and their neural regulatory mechanisms on the hypothalamus and autonomic nervous system, elucidating their impact on cardiovascular disease.

Methods

Review the basic and clinical studies on acupuncture signal transduction mechanisms and the role of the hypothalamus and ANS in acupuncture treatment of cardiovascular diseases published in four English databases (PubMed, Web of Science, MEDLINE, and Springer Cochrane Library) and two Chinese databases (Wanfang Database and China National Knowledge Infrastructure Database) over the past 20 years.

Results

Through sensory stimulation, acupuncture effectively transmits signals from the periphery to the hypothalamus, where they are integrated, and finally regulate the autonomic nervous system to treat cardiovascular diseases.

Discussion

Acupuncture exhibits significant potential as a therapeutic modality for cardiovascular diseases by orchestrating autonomic nervous system regulation via the hypothalamus, thereby gifting novel perspectives and methodologies for the prevention and treatment of cardiovascular ailments.

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.

Antiplatelet Therapy in Patients Requiring Oral Anticoagulation and Undergoing Percutaneous Coronary Intervention

Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is fundamental in all patients undergoing percutaneous coronary intervention (PCI) to prevent coronary thrombosis. In patients with atrial fibrillation (AF), an oral anticoagulant gives protection against ischemic stroke or systemic embolism. AF-PCI patients are at high bleeding risk and decision-making regarding the optimal antithrombotic therapy remains challenging. Dual antithrombotic therapy (DAT) has been shown to reduce bleeding events but at the cost of a higher risk of stent thrombosis. Further studies are needed to clarify the optimal duration of triple antithrombotic therapy (TAT) or DAT and the role of more potent antiplatelet drugs.

Management of atrial fibrillation in older adults

Most people with atrial fibrillation are older adults, in whom atrial fibrillation co-occurs with other chronic conditions, polypharmacy, and geriatric syndromes such as frailty. Yet most randomized controlled trials and expert guidelines use an age agnostic approach. Given the heterogeneity of aging, these data may not be universally applicable across the spectrum of older adults. This review synthesizes the available evidence and applies rigorous principles of aging science. After contextualizing the burden of comorbidities and geriatric syndromes in people with atrial fibrillation, it applies an aging focused approach to the pillars of atrial fibrillation management, describing screening for atrial fibrillation, lifestyle interventions, symptoms and complications, rate and rhythm control, coexisting heart failure, anticoagulation therapy, and left atrial appendage occlusion devices. Throughout, a framework is suggested that prioritizes patients' goals and applies existing evidence to all older adults, whether atrial fibrillation is their sole condition, one among many, or a bystander at the end of life.

Anticoagulant therapy in renal insufficiency theme: Anticoagulation in complex situations

Many patients with impaired renal function have concurrent indications for anticoagulant therapy, including atrial fibrillation and venous thromboembolism. For mild chronic kidney disease, data from clinical trials and existing guidelines can be applied to clinical management. The benefits and harms of anticoagulation therapy in patients with more advanced renal impairment are nuanced, as both thrombotic and bleeding risk are increased. Until recently, data regarding anticoagulants in severe renal impairment were primarily observational, but emerging evidence includes a few small clinical trials and the emergence of novel agents hypothesized to have improved efficacy and safety in this population. In this review, we summarize existing data on anticoagulation in patients with chronic kidney disease. We suggest a framework for anticoagulation decision-making in the burgeoning worldwide population of patients with chronic kidney disease.

In-hospital outcomes and postdischarge mortality in patients with acute coronary syndrome and atrial fibrillation

BACKGROUND

It is unclear whether advances in management of acute coronary syndrome (ACS) and introduction of novel oral anticoagulants have changed outcomes in patients with ACS with concomitant atrial fibrillation (AF).

OBJECTIVE

This study aimed to examine the incidence of AF in patients admitted for ACS and to evaluate its association with adverse outcomes, given the recent advances in management of both diseases.

METHODS

Natural language processing search algorithms identified AF in patients admitted with ACS across 13 Northwell Health Hospitals from 2015 to 2021. Hierarchical generalized linear mixed modeling was used to assess the association between AF and in-hospital mortality, bleeding, and stroke outcomes; marginal Cox regression modeling was used to assess the association between AF and postdischarge mortality.

RESULTS

Of 12,315 patients admitted for ACS, 3018 (24.5%) had AF with 1609 (53.3%) newly diagnosed. AF patients more commonly received anticoagulation with an oral anticoagulant (80.4% vs 12.3%) or heparin (61.9% vs 56.9%), had lengthier intensive care unit stay (72 vs 49 hours), and underwent fewer percutaneous coronary interventions (31.9% vs 53.1%). In-hospital bleeding, stroke, and mortality were higher in the AF group (15.3% vs 5.0%, 7.4% vs 2.4%, and 6.9% vs 2.1%, respectively). AF was an independent risk factor for all in-hospital outcomes (odds ratios of 2.5, 2.7, and 2.0 for bleeding, stroke, and mortality, respectively) as well as for postdischarge mortality (hazard ratio, 1.3; 95% CI, 1.2-1.5).

CONCLUSION

AF is present in 25% of ACS patients and increases risk of in-hospital and postdischarge adverse outcomes. Additional data are required to direct optimal management.

Clinical implications of combination proton pump inhibitor and triple therapies in patients with atrial fibrillation following percutaneous intervention: a guide for clinicians

INTRODUCTION

Patients on systemic oral anticoagulation with vitamin K antagonists (VKA) or non-vitamin K oral anticoagulants (NOAC) often require triple therapy following percutaneous coronary intervention, substantially increasing the risk of bleeding. Gastroprotective agents like proton pump inhibitors (PPI) are often employed to mitigate this risk, despite potential competitive inhibition between P2Y12-receptor inhibitors, NOACs, and VKAs. While the interactions and clinical outcomes of PPIs and DAPT have been frequently explored in literature, not many studies have evaluated the same outcomes for triple therapy.

AREAS COVERED

This comprehensive narrative review of three studies on PPIs and triple from the PubMed/MEDLINE database supplemented by 23 other relevant studies aims to use the available literature to analyze the potential interactions between PPIs and triple therapy while shedding light on their mechanisms, clinical implications, and areas for optimization.

EXPERT OPINION

If triple therapy is indicated following PCI, then patients at high-risk for bleeding may benefit from transition to apixaban and a PPI to lower the risk of gastrointestinal bleeding. More research is needed to determine the role of PPIs in triple therapies in prevention of gastrointestinal bleeding or potentiation of other adverse outcomes.

Prescribing of Proton Pump Inhibitors for Prevention of Upper Gastrointestinal Bleeding in US Outpatient Visits

Antisecretory medications, primarily proton pump inhibitors (PPIs), have proven effective in reducing upper gastrointestinal toxicities, including upper gastrointestinal bleeding (UGIB), associated with nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, which are among the most commonly used medications in the United States.1 Accordingly, professional guidance recommends PPIs for patients at high risk for UGIB.2-4 However, little is known about trends in use of antisecretory medications for gastrointestinal prophylaxis ("gastroprotection"). Herein, we examined contemporary use and prescribing of antisecretory medications in visits by patients at high risk for UGIB, relative to visits by patients diagnosed with acid-related disorders.

Outcomes of newly diagnosed atrial fibrillation in patients with acute coronary syndromes

BACKGROUND

Acute coronary syndrome (ACS) is frequently accompanied by newly diagnosed atrial fibrillation (AF).

AIMS

We aimed to compare the risk of major adverse cardiovascular events (MACE) in ACS patients presenting with known, newly diagnosed, or no AF.

METHODS

In our multicentre, prospective registry study, we included patients with confirmed ACS. Patients are classified as having known, newly diagnosed or no AF. Newly diagnosed AF is subdivided according to the duration of the episode, time of onset, post-coronary artery bypass graft (CABG) or spontaneous occurrence, and treatment with oral anticoagulants (OAC). The primary endpoint is MACE at 1 year. Key secondary endpoints include ischaemic stroke and bleeding complications.

RESULTS

Amongst 4,433 patients with confirmed ACS, 3,598 (81.2%) had no AF, 438 (9.9%) had newly diagnosed AF, and 397 (9.0%) had known AF. The rates of OAC treatment at discharge were 53.4% in patients with newly diagnosed AF and 89.2% in patients with known AF. After adjusting for baseline imbalances, only new AF was independently associated with increased rates of MACE, whereas known AF was not (hazard ratio [HR] 1.52, 95% confidence interval [CI]: 1.19-1.90 and HR 0.93, 95% CI: 0.70-1.23). For ACS patients with newly diagnosed AF, episodes lasting >24 hours were associated with a higher risk of MACE compared to episodes <24 hours (HR 1.99, 95% CI: 1.36-2.93). Episodes of new AF occurring post-CABG had more favourable outcomes compared to spontaneously occurring new AF (HR for MACE 0.52, 95% CI: 0.31-0.86). OAC treatment rates were higher in the new AF subcategories with higher rates of MACE and ischaemic stroke.

CONCLUSIONS

Newly diagnosed AF in ACS patients was associated with higher rates of MACE and ischaemic stroke compared to ACS patients without or with known AF. Among the ACS patients with new AF, an episode lasting >24 hours was associated with worse outcomes than shorter episodes, while post-CABG occurrence of AF showed relatively better outcomes compared to spontaneously occurring AF. Only 53% of new AF patients were discharged on OAC therapy versus 89% with known AF.

Analysis of appropriateness and safety when discharging patients on triple-antithrombotic therapies

PURPOSE

To analyze the appropriateness of triple-antithrombotic therapy based on the 2020 American College of Cardiology (ACC) consensus statement while evaluating safety outcomes for patients with respect to adverse events.

METHODS

A single-center, retrospective chart review was conducted using electronic medical records from December 18, 2020, to August 31, 2022. The primary endpoint was the rate of appropriateness for triple-antithrombotic therapy in patients discharged from Ochsner LSU Health Shreveport. Appropriateness was a composite endpoint extrapolated from the 2020 ACC consensus statement. For therapy to be defined as appropriate, patients had to have had the correct therapy indication, medications, dosing, and 30-day duration. Secondary safety endpoints included the percentage of patients rehospitalized at 14 and 30 days, the rate of major bleeding events, and the percentage of patients on gastrointestinal prophylaxis while on triple-antithrombotic therapy.

RESULTS

A total of 93 patients were included in the study, of whom 31 (33%) received appropriate triple-antithrombotic therapy. Prolonged duration of triple-antithrombotic therapy was the most common reason that therapy did not meet the primary endpoint. The readmission rate due to bleeding was 2.2% at 14 days and 6.5% at 30 days. Within 30 days of initiation of triple therapy, 4.3% of patients endured major bleeding as defined by the International Society on Thrombosis and Hemostasis and 2 patients died.

CONCLUSION

In this single-center study, triple-antithrombotic therapy appropriately adhered to the 2020 ACC consensus statement for one-third of patients discharged on this therapy.

Design and rationale for REVERXaL: A real-world study of patients with factor Xa inhibitor-associated major bleeds

BACKGROUND

The prevalence of anticoagulation treatment is increasing as an aging global population faces a high burden of cardiovascular comorbidities. Direct oral anticoagulants, including factor Xa inhibitors (FXai), are replacing vitamin K antagonists as the most commonly prescribed treatment for reducing risk of thrombotic events. While the risk of FXai-associated spontaneous bleeds is established, less is understood about their management and the effect of treatment on clinical and patient-reported outcomes. The primary objectives of the REVERXaL study are to describe patient characteristics, health care interventions during the acute-care phase, in-hospital outcomes, and associations between timing of reversal/replacement agent administration and in-hospital outcomes. Secondary/exploratory objectives focus on clinical assessments and patient-reported outcome measures (PROMs) at 30 and 90 days.

METHODS

REVERXaL is a multinational, observational study of hospitalized patients with FXai-associated major bleeds in Germany, Japan, the United Kingdom, and the United States. The study includes 2 cohorts of approximately 2000 patients each. Cohort A is a historic cohort for whom medical chart data will be collected from hospitalization to discharge for patients admitted for major bleeds during FXai use within 2 years prior to enrollment of Cohort B. Cohort B will prospectively enroll patients administered any reversal/replacement agent during hospitalization to manage FXai-associated major bleeds and will include the collection of clinical outcomes and PROMs data over 3 months.

CONCLUSIONS

REVERXaL will generate insights on patient characteristics, treatment approaches, and associated outcomes in patients hospitalized with FXai-associated major bleeds. These data may inform clinical practice and streamline treatment pathways in this population.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; unique identifier: NCT06147830.

Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease

Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.

To treat or not to treat: a comparative effectiveness analysis of oral anticoagulant outcomes among U.S. nursing home residents with atrial fibrillation

BACKGROUND

Nursing home residents with atrial fibrillation are at high risk for ischemic stroke, but most are not treated with anticoagulants. This study compared the effectiveness and safety between oral anticoagulant (OAC) users and non-users.

METHODS

We conducted a new-user retrospective cohort study by using Minimum Data Set 3.0 assessments linked with Medicare claims. The participants were Medicare fee-for-service beneficiaries with atrial fibrillation residing in US nursing homes between 2011 and 2016, aged ≥ 65 years. The primary outcomes were occurrence of an ischemic stroke or systemic embolism (effectiveness), occurrence of intracranial or extracranial bleeding (safety) and net clinical outcome (effectiveness or safety outcomes). Secondary outcomes included total mortality and a net clinical and mortality outcome. Cox proportional hazards and Fine and Grey models estimated multivariable adjusted hazard ratios (aHRs) and sub-distribution hazard ratios (sHRs).

RESULTS

Outcome rates were low (effectiveness: OAC: 0.86; non-users: 1.73; safety: OAC: 2.26; non-users: 1.75 (per 100 person-years)). OAC use was associated with a lower rate of the effectiveness outcome (sHR: 0.69; 95% Confidence Interval (CI): 0.61-0.77), higher rates of the safety (sHR: 1.70; 95% CI: 1.58-1.84) and net clinical outcomes (sHR: 1.20; 95% CI: 1.13-1.28) lower rate of all-cause mortality outcome (sHR: 0.60; 95% CI: 0.59-0.61), and lower rate of the net clinical and mortality outcome (sHR: 0.60; 95% CI: 0.59-0.61). Warfarin users, but not DOAC users, had a higher rate of the net clinical outcome versus OAC non-users.

CONCLUSIONS

Our results support the benefits of treatment with OACs to prevent ischemic strokes and increase longevity, while highlighting the need to weigh apparent benefits against elevated risk for bleeding. Results were consistent with net favorability of DOACs versus warfarin.

Antithrombotic therapy at discharge and prognosis in patients with chronic coronary syndrome and atrial fibrillation who underwent PCI: a real-world study

BACKGROUND

This study aimed to describe the status of antithrombotic therapy at discharge and prognosis in patients with atrial fibrillation (AF) and chronic coronary syndrome (CCS) who underwent percutaneous coronary intervention (PCI).

METHODS

This was an observational, prospective study. The primary endpoint was major adverse cardiovascular events (MACE), including all-cause death, myocardial infarction, stroke/transient ischemic attach (TIA), systemic embolism or ischemia-driven revascularization. Bleeding events were collected according to the Thrombolysis in Myocardial Infarction (TIMI) criteria.

RESULTS

Between 2017 and 2019, a cohort of 516 patients (mean age 66, [SD 9], of whom 18.4% were female) with AF and CCS who underwent PCI were evaluated, with a median followed-up time of 36 months (Interquartile range: 22-45). MACE events occurred in 13.0% of the patients, while the TIMI bleeding events were observed in 17.4%. Utilization of TAT (triple antithrombotic therapy) (P < 0.001) and oral anticoagulation (OAC) therapy (P < 0.001) increased through years. History of heart failure (HF) (Hazard ratio [HR], 1.744; 95% confidence interval [CI], 1.011-3.038) and TAT (HR, 2.708; 95%CI, 1.653-4.436) had independent associations with MACE events. OAC (HR, 10.378; 95%CI, 6.136-17.555) was identified as a risk factor for bleeding events. A higher creatine clearance (HR, 0.986; 95%CI, 0.974-0.997) was associated with a lower incidence of bleeding events.

CONCLUSIONS

Antithrombotic therapy has been improved among patients with AF and CCS who underwent PCI these years. History of HF and TAT were independently associated with MACE events. Higher creatine clearance was protective factor of bleeding events, while OAC was a risk factor for TIMI bleeding events.

Antithrombotic Therapy in Cancer Patients with Cardiovascular Diseases: Daily Practice Recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO) and the Society for Thrombosis and Hemostasis Research (GTH e.V.)

Active cancer by itself but also chemotherapy is associated with an increased risk of cardiovascular disease (CVD) and especially coronary artery disease (CAD) and atrial fibrillation (AF). The frequency of CVD, CAD, and AF varies depending on comorbidities (particularly in older patients), cancer type, and stage, as well as the anticancer therapeutic being taken. Many reports exist for anticancer drugs being associated with CVD, CAD, and AF, but robust data are often lacking. Because of this, each patient needs an individual structured approach concerning thromboembolic and bleeding risk, drug-drug interactions, as well as patient preferences to evaluate the need for anticoagulation therapy and targeting optimal symptom control. Interruption of specific cancer therapy should be avoided to reduce the potential risk of cancer progression. Nevertheless, additional factors like thrombocytopenia and anticoagulation in the elderly and frail patient with cancer cause additional challenges which need to be addressed in daily clinical management. Therefore, the aim of these recommendations is to summarize the available scientific data on antithrombotic therapy (both antiplatelet and anticoagulant therapy) in cancer patients with CVD and in cases of missing data providing guidance for optimal careful decision-making in daily routine.