Incidence of Ventricular Fibrillation and Sustained Ventricular Tachycardia Complicating Non-ST Segment Elevation Myocardial Infarction

Background: Primary ventricular fibrillation (VF) and sustained ventricular tachycardia (VT) are potentially lethal complications in patients suffering from acute myocardial infarction (MI). In contrast with the profound data regarding the incidence and prognostic value of ventricular arrhythmias in ST elevation myocardial infarction (STEMI) patients, data regarding contemporary non-ST elevation myocardial infarction (NSTEMI) patients with ventricular arrhythmias is scarce. The aim of the current study was to investigate the incidence of VF/VT complicating NSTEMI among patients admitted to an intensive coronary care unit (ICCU). Methods: Prospective, single-center study of patients diagnosed with NSTEMI admitted to ICCU between June 2019 and December 2022. Data including demographics, presenting symptoms, comorbid conditions, and physical examination, as well as laboratory and imaging data, were analyzed. Patients were continuously monitored for arrhythmias during their admission. The study endpoint was the development of VF/sustained VT during admission. Results: A total of 732 patients were admitted to ICCU with a diagnosis of NSTEMI. Of them, six (0.8%) patients developed VF/VT during their admission. Nevertheless, three were excluded after they were misdiagnosed with NSTEMI instead of posterior ST elevation myocardial infarction (STEMI). Hence, only three (0.4%) NSTEMI patients had VF/VT during admission. None of the patients died during 1-year follow-up. Conclusions: VF/VT in NSTEMI patients treated according to contemporary guidelines including early invasive strategy is rare, suggesting these patients may not need routine monitoring and ICCU setup.

Treatment adherence in patients without ST-elevation acute coronary syndrome

BACKGROUND

Despite progress during the last decades, patients with coronary artery disease (CAD) remain with a high residual risk due to multiple reasons. Optimal medical treatment (OMT) provides a decrease of recurrent ischemic events after acute coronary syndrome (ACS). Therefore, treatment adherence results crucial to reduce further outcomes after the index event. No recent data are available in Argentinian population; the main objective of our study was to evaluate the adherence at 6 and 15 months in post non-ST elevation acute coronary syndrome (NST-ACS) consecutive patients. Secondary objective was to evaluate the relationship of adherence with 15-month events.

METHODS

A prespecified sub-analysis in the prospective registry Buenos Aires I was performed. The adherence was evaluated using the modified Morisky-Green Scale.

RESULTS

A number of 872 patients had information about adherence profile. Of them 76.4% were classified as adherents at month 6 and 83.6% at 15 (P=0.06). We did not find any difference in baseline characteristic between the adherent and non-adherent patients at 6 months. The adjusted analysis showed that non-adherent patients had a rate of ischemic events at 15th month of 20% (27/135) vs. 11.5% (52/452) in adherent patients (P=0.001). The bleeding events defined were of 3.6% in the non-adherent group vs. 5% in the adherent group without a statistical difference (P=0.238).

CONCLUSIONS

Adherence to treatment is still a major issue as almost 25% of patients should be considered as non-adherent to OMT. No clinical predictor of this phenomenon was identified but our criteria were not exhaustive. Good adherence to treatment was highly associated to a reduction of ischemic events, whereas no impact on bleeding events was found. These data support a better network and collaboration with shared decision between healthcare professionals with patients and family members to improve acceptance and adherence to optimal medical strategies.

Establishing a multi-specialty consensus in the clinical need for hypercholesterolemia management and its implication for patients access to innovative therapies

BACKGROUND

Increased level of blood LDL-C has a causal and cumulative effect on advancing atherosclerotic cardiovascular diseases (ASCVD). European guidelines for treating high LDL-C levels have been recently updated. However, in France, several challenges (e.g., physician and patient awareness, healthcare management) limit the application of management guidelines. The aim of this study was to understand the current opinions and perceived unmet clinical needs in recognising and managing hypercholesterolemia as an ASCVD risk factor, and to explore consensus around factors that support the effective management of elevated LDL-C.

METHODS

An expert group of cardiologists, endocrinologists, biology/genetics researchers, and a health technology assessments expert, from France was convened. The current management of hypercholesterolemia and barriers to achieving LDL-C goals in France were discussed and 44 statements were developed. Wider consensus was assessed by sending the statements as a 4-point Likert Scale questionnaire to cardiologists and endocrinologists across France. The consensus threshold was defined as ≥75%.

RESULTS

A total of 101 responses were received. Consensus was very high (>90%) in 25 (57%) statements, high (≥75%) in 18 (41%) statements and was not achieved (<75%) only in 1 (2%) of statements. Overall, 43 statements achieved consensus.

CONCLUSIONS

Based on consensus levels, key recommendations for improving current guidelines and approaches to care have been developed. Implementation of these recommendations will lead to better concordance with international treatment guidelines and increase levels of education for healthcare practitioners and patients. In turn, this will improve the available treatment pathways for cardiovascular diseases, potentially creating improved patient outcomes in the future.

Atherosclerotic Plaque Erosion: Mechanisms, Clinical Implications, and potential therapeutic Strategies - a review

Atherosclerosis is an insidious and progressive inflammatory disease characterized by the formation of lipid-laden plaques within the intima of arterial walls with potentially devastating consequences. While rupture of vulnerable plaques has been extensively studied, a distinct mechanism known as plaque erosion has gained recognition and attention in recent years. Plaque erosion, characterized by the loss of endothelial cell lining in the presence of intact fibrous cap contributes to a significant and growing proportion of acute coronary events. However, despite a heterogenous substrate underlying coronary thrombosis, treatment remains identical. This article provides an overview of atherosclerotic plaque erosion characteristics and its underlying mechanisms, highlights its clinical implications, and discusses potential therapeutic strategies.

[Natriuretic peptides in the diagnosis and monitoring of heart failure]

NATRIURETIC PEPTIDES IN THE DIAGNOSIS AND MONITORING OF CARDIAC FAILURE. Heart failure (HF) is a serious and common disease requiring a prompt diagnosis for appropriate management. Natriuretic peptides, such as BNP and NT-proBNP, play a crucial role in diagnosing HF due to their s pecificity and reproducibility. It is important to measuring natriuretic peptides, especially in cases of acute dyspnea, to differentiate cardiac causes from others. Specific thresholds are recommended, with high values strongly suggest HF, while normal levels rule out the diagnosis. Clinical characteristics, such as age, renal function, atrial fibrillation, obesity, and gender, influence natriuretic peptides levels and should be considered in interpretation. For diabetic, hypertensive, and obese patients, early screening for HF through natriuretic peptides measurement is crucial. Furthermore, these natriuretic peptides are useful for monitoring chronic heart failure patients. They assist in confirming decompensation, titrating treatment, evaluating treatment response, and establishing prognosis. However, it's essential to choose a single biomarker (BNP or NT-proBNP) to avoid confusion.

Blockchain technology in Cardiovascular Medicine: a glance to the future? Results from a social media survey and future perspectives

The leverage of digital facilities in medicine for disease diagnosis, monitoring, and medical history recording has become increasingly pivotal. However, the advancement of these technologies poses a significant challenge regarding data privacy, given the highly sensitive nature of medical information. In this context, the application of Blockchain technology, a digital system where information is stored in blocks and each block is linked to the one before, has the potential to enhance existing technologies through its exceptional security and transparency. This paradigm is of particular importance in cardiovascular medicine, where the prevalence of chronic conditions leads to the need for secure remote monitoring, secure data storage and secure medical history updating. Indeed, digital support for chronic cardiovascular pathologies is getting more and more crucial. This paper lays its rationale in three primary aims: 1) to scrutinize the existing literature for tangible applications of blockchain technology in the field of cardiology; 2) to report results from a survey aimed at gauging the reception of blockchain technology within the cardiovascular community, conducted on social media; 3) to conceptualize a web application tailored specifically to cardiovascular care based on blockchain technology. We believe that Blockchain technology may contribute to a breakthrough in healthcare digitalization, especially in the field of cardiology; in this context, we hope that the present work may be inspiring for physicians and healthcare stakeholders.

Lifestyle and Lipoprotein(a) Levels: Does a Specific Counseling Make Sense?

Lipoprotein(Lp)(a) is a variant of low-density lipoprotein (LDL), bound to apolipoprotein B100, whose levels are associated with a significant increase in the risk of atherosclerosis-related cardiovascular events, but also to aortic stenosis and atrial fibrillation. Since plasma levels of Lp(a) are commonly considered resistant to lifestyle changes, we critically reviewed the available evidence on the effect of weight loss, dietary supplements, and physical activity on this risk factor. In our review, we observed that relevant body weight loss, a relatively high intake of saturated fatty acids, the consumption of red wine, and intense physical exercise seems to be associated with significantly lower plasma Lp(a) levels. On the contrary, foods rich in trans-unsaturated fatty acids are associated with increased Lp(a) levels. With regard to dietary supplements, coenzyme Q10, L-Carnitine, and flaxseed exert a mild but significant lowering effect on plasma Lp(a).

French expert group proposal for lipid-lowering therapy in the first 3 months after acute myocardial infarction

In patients admitted for acute myocardial infarction (MI), it has been demonstrated that reducing LDL cholesterol (LDL-c) is associated with a reduction in major adverse cardiovascular events. We describe a consensual proposal made by a French group of experts for lipid-lowering therapy at the acute phase of acute myocardial infarction. A group of French experts comprising cardiologists, lipidologists and general practitioners prepared a proposal for a lipid-lowering strategy with a view to optimizing LDL-c levels in patients hospitalized for myocardial infarction. We describe a strategy for the use of statins, ezetimibe and and/or proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, with a view to reaching target LDL-c levels as early as possible. This approach, which is currently feasible in France, could considerably improve lipid management in patients after ACS, thanks to its simplicity, rapidity and the magnitude of the decrease in LDL-c that it achieves.

Insulin analogs as an add-on to metformin after failure to oral treatment in type 2 diabetic patients increase diastole duration. The INSUlin Regimens and VASCular Functions (INSUVASC) study

BACKGROUND

Fast acting insulin analogues are known to improve arterial stiffness. The combination of metformin with insulin represents a widely used therapeutic strategy in diabetes. We hypothesized that insulin treatment in patients with type 2 diabetes (T2D) with long-acting, fast-acting or basal bolus insulin as an add-on to metformin would provide additional improvement of arterial stiffness.

METHODS

The INSUlin Regimens and VASCular Functions (INSUVASC) study is a pilot, randomized, open label three-arms study that included 42 patients with type 2 diabetes (T2D) in primary prevention, after a failure to oral antidiabetic agents. Arterial stiffness measurements were performed at fasting and after a standardized breakfast. During the first visit (V1) pre-randomization, participants took only metformin to perform the tests. The same tests were repeated after 4 weeks of insulin treatment during the second visit (V2).

RESULTS

Data were available for final analysis in 40 patients, with a mean age of 53.6±9.7 years and a mean duration of diabetes of 10.6±5.6 years. Twenty-one were females (52.5%), hypertension and dyslipidemia were present in 18 (45%) and 17 patients (42.5%), respectively. After insulin treatment, the metabolic control was associated to a decrease in oxidative stress and improvement of endothelial functions, with a post prandial diastole duration increased and a decrease of the peripheral arterial stiffness, with a better post prandial pulse pressure ratio and ejection duration after insulin. In hypertensive patients, insulin treatment provided positive effects by decreasing the pulse wave velocity and improving reflection time.

CONCLUSIONS

A short time treatment by insulin in addition to metformin improved myocardial perfusion. Moreover, insulin treatment in hypertensive patients provides a better hemodynamic profile in large arteries.

Characteristics of patients with atrial fibrillation treated with direct oral anticoagulants and new insights into inappropriate dosing: results from the French National Prospective Registry: PAFF

AIMS

Since the introduction of direct oral anticoagulant (DOAC) for atrial fibrillation (AF) therapy, inappropriate and/or underdosing of these drugs has been a major clinical challenge. We evaluated the characteristics of patients with AF treated with inappropriate and low-dose DOACs.

METHODS AND RESULTS

Patients with AF treated with inappropriate and low-dose DOACs from October 2021 to December 2021 were evaluated from the French National Prospective Registry (PAFF). We evaluated 1890 patients with AF receiving DOACs (apixaban 55%, dabigatran 7%, and rivaroxaban 38%). Inappropriate dosing was noted in 18% of the population. Patients with appropriate dosing had less comorbidities: younger age (75 ± 10 vs. 82 ± 8 years old, P < 0.0001), reduced chronic renal failure (26 vs. 61%, P < 0.0001), and lower CHA2DS2VASc and HASBLED scores (3 ± 2 vs. 4 ± 3, P < 0.0001; 2 ±1 vs. 2 ± 2, P < 0.0001), respectively. In multivariate analysis, older age (P < 0.0001) and a higher CHA2DS2VASc score (P = 0.0056) were independently associated with inappropriate DOAC dosing. Among 472 patients (27%) treated with low-dose rivaroxaban or apixaban, 46% were inappropriately underdosed. Patients inappropriately underdosed were younger (82.3 ± 8.4 vs. 85.9 ± 5.9 years, P < 0.0001) with less chronic renal disease (47 vs. 98%, P < 0.0001). However, these patients had higher rates of prior haemorrhagic events (18 vs. 10%, P = 0.01), clopidogrel use (11 vs. 3%, P = 0.0002), and apixaban prescription (74 vs. 50%, P < 0.0001).

CONCLUSION

Within this large registry, DOACs were associated with inappropriate dosing in 18% of cases. Independent predictors of inappropriate dosing were high CHA2DS2VASc scores and older age. Moreover, 46% of patients treated with low-dose DOACs were inappropriately underdosed and more frequently in patients treated with apixaban.

Optimisation of treatments for heart failure with reduced ejection fraction in routine practice: a position statement from a panel of experts

Major international practice guidelines recommend the use of a combination of 4 medication classes in the treatment of patients with heart failure with reduced ejection fraction (HFrEF) but do not specify how these treatments should be introduced and up-titrated. Consequently, many patients with HFrEF do not receive an optimized treatment regimen. This review proposes a pragmatic algorithm for treatment optimization designed to be easily applied in routine practice. The first goal is to ensure that all 4 recommended medication classes are initiated as early as possible to establish effective therapy, even at a low dose. This is considered preferable to starting fewer medications at a maximum dose. The second goal is to ensure that the intervals between the introduction of different medications and between different titration steps are as short as possible to ensure patient safety. Specific proposals are made for older patients (> 75 years) who are frail, and for those with cardiac rhythm disorders. Application of this algorithm should allow an optimal treatment protocol to be achieved within 2-months in most patients, which should the treatment goal in HFrEF.

The relationship between mortality and daily number of steps in type 2 diabetes

BACKGROUND

Physical activity (PA) is an established modifiable factor for the prevention of cardiovascular disease. Our objective was to assess the association of PA with mortality rates in a national sample of patients with diabetes.

METHODS

We analyzed a nationally representative sample from The National Health and Nutrition Examination Survey (NHANES, periods 2003-2004 and 2005-2006) that used PA Monitors. Individuals were matched for BMI, number of steps/per day and age. Three groups were created: subjects with less than 5000/steps per day (low), 5000-7500/steps per day (moderate) and more than 7500/steps per day (high levels of physical activity). All-cause mortality was ascertained through December 2015.

RESULTS

A sample of 3072 individuals (1018 with diabetes) was analyzed. Patients with diabetes had 30% increased risk of mortality of all causes (RR: 1.298, 95% CI [1.162-1.451], P<0.001), higher levels of PA (>7500 steps/day) provided similar relative risk for subjects with diabetes compared to their controls (RR:1.256 [95% CI 0.910-1.732]). In a Poisson model adjusted for sex, history of previous cardiovascular event or cancer, ethnicity, Hb1ac, SBP, and total cholesterol to HDL ratio, patients with diabetes and moderate or high PA had an associated 44% to 80% lower risk of all-cause mortality compared to those with low PA.

CONCLUSIONS

The subgroup of patients with diabetes and high PA had no excess of mortality compared to the general population. PA can reduce the gap for all-cause mortality, used as an index of cardiovascular fitness and a clinical tool for the assessment of mortality risk.

Role of Cardiovascular Imaging in Risk Assessment: Recent Advances, Gaps in Evidence, and Future Directions

Optimal risk assessment for primary prevention remains highly challenging. Recent registries have highlighted major discrepancies between guidelines and daily practice. Although guidelines have improved over time and provide updated risk scores, they still fail to identify a significant proportion of at-risk individuals, who then miss out on effective prevention measures until their initial ischemic events. Cardiovascular imaging is progressively assuming an increasingly pivotal role, playing a crucial part in enhancing the meticulous categorization of individuals according to their risk profiles, thus enabling the customization of precise therapeutic strategies for patients with increased cardiovascular risks. For the most part, the current approach to patients with atherosclerotic cardiovascular disease (ASCVD) is homogeneous. However, data from registries (e.g., REACH, CORONOR) and randomized clinical trials (e.g., COMPASS, FOURIER, and ODYSSEY outcomes) highlight heterogeneity in the risks of recurrent ischemic events, which are especially higher in patients with poly-vascular disease and/or multivessel coronary disease. This indicates the need for a more individualized strategy and further research to improve definitions of individual residual risk, with a view of intensifying treatments in the subgroups with very high residual risk. In this narrative review, we discuss advances in cardiovascular imaging, its current place in the guidelines, the gaps in evidence, and perspectives for primary and secondary prevention to improve risk assessment and therapeutic strategies using cardiovascular imaging.

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence

Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.

Body Mass Index and All-Cause and Cardiovascular Mortality in United States Adults With and Without Atherosclerotic Cardiovascular Disease: Findings from the National Health Interview Survey

In a nationally representative population-based study of US adults, the authors sought to examine the association between body mass index (BMI) and all-cause and cardiovascular disease (CVD) mortality in a nationally representative sample of adults with and without atherosclerotic cardiovascular disease (ASCVD), and further stratified by age, sex, and race/ethnicity. The study used data from 2006 to 2015 National Health Interview Survey and categorized participants into the following BMI categories: normal weight (20-24.9), overweight (25-29.9), obesity class 1 (30-34.9), obesity class 2 (35-39.9), and obesity class 3 (≥40 kg/m2). Multivariable Cox proportional hazards models were used to assess the risk of all-cause and CVD mortality across successively increasing BMI categories overall, and by sociodemographic subgroups. A total of 210,923 individuals were included in the final analysis. In the population without ASCVD, the risk of all-cause and CVD mortality was lower in overweight and higher in obesity classes 2 and 3, compared with normal weight, with the highest risk observed in the young adult (age 18-39) population. Elderly adults (65 and above) and populations with ASCVD exhibited a BMI-mortality paradox. In addition, Hispanic individuals did not show a relationship between BMI and mortality compared with non-Hispanic White and Black adults. In conclusion, being overweight was associated with decreased risk, whereas obesity class 3 was consistently associated with increased risk of all-cause and CVD mortality in adults without ASCVD, particularly young adults. BMI-mortality paradox was noted in ASCVD, elderly, and non-Hispanic adults.

Lipid-lowering treatment up to one year after acute coronary syndrome: guidance from a French expert panel for the implementation of guidelines in practice

The management of patients with coronary artery disease (CAD) is complex, especially after they have been discharged from hospital after an acute coronary syndrome (ACS), because each patient may have numerous healthcare providers, and follow-up after discharge may be disjointed, or even incomplete. During follow-up after ACS, few patients have treatment intensification; rather, there is actually a major tendency towards reductions in treatment intensity, to the potential detriment of outcomes. We present here guidance from a French expert panel for the optimal management of lipid-lowering therapy up to 1 year after ACS. A French expert panel provides a practical guide for the implementation of guidelines for the management of post-ACS patients in routine practice, from hospital discharge up to one year after the index event, focusing in particular on the achievement of target LDL cholesterol (LDL-C) levels. We discuss the early follow-up (up to 6 months after discharge) and review the lipid-lowering treatment strategies that should be implemented. We discuss the evidence underpinning the prescription of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors as well as recent evidence about icosapent ethyl. This review should facilitate implementation of a clear and effective lipid-lowering strategy for all patients after ACS. The panel recommends early use of high-intensity statins, in combination with ezetimibe for patients with LDL-c above 100 mg/dL at baseline. PCSK9i should be rapidly added during the first 3 months in high-risk diabetic patients with residual LDL-C above 70 mg/dL (with further benefit for those with residual LDL-C above ≥100 mg/dL) despite maximal tolerated dose statin and ezetimibe, patients with recent ACS, and patients with recurrent ischemic events under optimal medical therapy, multivessel coronary disease (MVD) and/or polyvascular disease (PVD), especially symptomatic PAD diabetic patients. Concerning icosapent ethyl (EPA), this drug should be introduced in patients ≥45 years of age with clinical atherosclerotic cardiovascular disease (ASCVD) or already on high-intensity or maximally tolerated statin therapy or with fasting triglycerides 135-499 mg/dL (with or without ezetimibe). Lipid-lowering treatment should be introduced as early as possible to obtain a rapid and profound decrease of LDL-c from baseline, using high-intensity statins (atorvastatin or rosuvastatin) and ezetimibe in fixed combination before discharge. Then, the strategy should be rapidly intensified by adding a PCSK9 inhibitor if the patient does not reach LDL-c levels below 55 mg/dL. We advocate this intensive strategy, which has demonstrated a further reduction in ischemic events, without safety concerns, even for patients who reach very low LDL-cholesterol levels. This approach, comprising few therapeutic steps, aims to rapidly reach LDL-c goals, improve patient compliance, and is an efficient method to fight therapeutic inertia, which remains a major issue.

De-escalation of antiplatelet therapy in patients with coronary artery disease: Time to change our strategy?

Dual antiplatelet therapy (DAPT) is the gold standard after acute coronary syndromes (ACS) or chronic coronary syndromes (CCS) undergoing percutaneous coronary intervention (PCI). Because local and systemic ischemic complications can occur particularly in the early phase (i.e. 1-3 months) after ACS or PCI, the synergistic platelet inhibition of aspirin and a P2Y₁₂ inhibitor is of the utmost importance in this early phase. Moreover, the use of the more potent P2Y₁₂ inhibitors prasugrel and ticagrelor have shown to further reduce the incidence of ischemic events compared to clopidogrel after an ACS. On the other hand, prolonged and potent antiplatelet therapy are inevitably associated with increased bleeding, which unlike thrombotic risk, tends to be stable over time and may outweigh the benefit of reducing ischemic events in these patients. The duration and composition of antiplatelet therapy remains a topic of debate in cardiology due to competing ischemic and bleeding risks, with guidelines and recommendations considerably evolving in the past years. An emerging strategy, called "de-escalation", consisting in the administration of a less intense antithrombotic therapy after a short course of standard DAPT, has shown to reduce bleeding without any trade-off in ischemic events. De-escalation may be achieved with different antithrombotic strategies and can be either unguided or guided by platelet function or genetic testing. The aim of this review is to summarize the evidence and provide practical recommendations on the use of different de-escalation strategies in patients with ACS and CCS.

Prevention and treatment of premature ischaemic heart disease with European Society of Cardiology Guidelines

OBJECTIVE

To determine if the changes in the European Society Cardiology/European Atherosclerotic Society (ESC/EAS) guidelines improved the identification for primary prevention therapy in young adults at risk of a premature myocardial infarction.

METHODS

Patients admitted for a first ST-segment elevation myocardial infarction (STEMI) in the ePARIS registry (n=2757) between 2010 and 2018 were classified by age: <55, 55-65 and >65 years old. Using Systematic Coronary Risk Estimation 2, we evaluated whether patients would have been detected and treated with primary prevention statins before their first STEMI based on the 2021 EAS/ESC guidelines versus 2019 and 2016 guidelines. Eligibility for intensive proprotein convertase subtilisin/kexin type 9 (PCSK9i) in secondary prevention was also assessed.

RESULTS

Following 2021 ESC guidelines, 62.5% of individuals aged <55 years old would have been eligible for statins before their first STEMI, similarly to older age categories. In comparison, only 17% and 18% of young individuals would have been eligible for primary prevention statins prior to their first STEMI with 2016 and 2019 guidelines, compared with group 55-65 years (41% and 35%) and >65 years old (19% and 72%), p<0.01. After their first STEMI, 25% of patients <55 years would be eligible for PCSK9i, compared with 23.2% and 15% in patients aged 55-65 years and >65 years.

CONCLUSIONS

The 2021 ESC guidelines allowed a much better detection of young individuals before their first STEMI than prior ESC guidelines. In secondary prevention, most of young individuals did not reach low-density lipoprotein cholesterol levels recommended, but only one quarter would be eligible for PCSK9i.

Suction drainage in total knee replacement does not influence early functional outcomes or blood loss: a randomized control trial

INTRODUCTION

The use of wound drainage following total knee arthroplasty (TKA) remains controversial. The purpose of this study was to evaluate the impact of suction drainage on early postoperative outcomes in patients who underwent TKA with concomitant administration of intravenous tranexamic acid (TXA).

METHOD

One hundred forty-six patients undergoing primary TKA with systematic intravenous TXA were prospectively selected and randomly divided into two groups. The first "Study group" (n = 67) received no suction drain and the second "Control" group (n = 79) had a suction drain. Perioperative hemoglobin levels, blood loss, complications, and length of hospital stay were assessed in both groups. Preoperative and postoperative range of motion and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were also compared at a 6-week follow-up.

RESULTS

The study group was found to have higher hemoglobin levels preoperatively and during the first two days following surgery, and no difference was found between the groups on the third day. No significant discrepancies at any time were found between groups in terms of blood loss, length of hospitalization, knee range of motion, and KOOS score. Complications requiring further treatment were observed in one patient from the study group and ten patients from the control group.

CONCLUSION

The use of suction drains after TKA with TXA did not alter early postoperative outcomes.

Atrial fibrillation diagnosis by a systematic 14-day continuous ECG-Holter in patients with high cardiovascular risk and clinical palpitation: the prospective AFTER study

Background

Atrial Fibrillation (AF) is asymptomatic in 20–30% of cases. New technologic tools for continuous ECG monitoring have been developed to detect and potentially treat AF in specific population with high cardiovascular risk.

Purpose

We aimed to evaluate the prevalence and the management of AF diagnosed in patients with no previous documented AF but with a high cardiovascular risk and clinical palpitation undergoing systematic 14-day continuous ECG-Holter monitoring and associated characteristics.

Methods

Patients were prospectively enrolled from December 2019 to December 2021 in this multicentered study, sponsored by the French National College of Cardiology. Patients needed to meet the following criteria: CHA2DS2VASc score ≥3 in women &gt;2 in men associated with clinical palpitation without previous documented arrhythmia, particularly AF. Exclusion criteria were: previous documented AF, participation to another study that could interfere with the current study, pregnancy, previous skin intolerance to ECG-Holter electrodes. Included patients underwent a 14-day monitoring Holter-ECG to detect cardiac arrhythmia, particularly AF. Patients' characteristics, type of arrythmias and management of detected AF were described.

Results

Among the 336 included patients, 39% were men, median age was 73 [64.5–78] years, 71.5% had hypertension and 46.5% had a previous history of stroke. AF was detected in 14% of patients, among which 23.4% in the first 24 hours monitoring. In univariate analyses, older age (p=0.045) was significantly associated with AF, and a trend was observed regarding male gender (p=0.067) and less antiplatelet therapy (p=0.058). Patients with diagnosed AF had a prescription of anticoagulation therapy in 90% of cases consisting in apixaban and rivaroxaban for 72% and 28% respectively. Antiarrhythmic drugs were administered in 90% of AF patients and 13% underwent AF ablation.

Conclusions

The systematic AF screening of selected patients based on CHA2DS2VASc score ≥3 in women &gt;2 in men associated with palpitations allows to diagnose AF in 14% of the population with a 14-day continuous ECG-Holter. This strategy seems efficient as it induced the prescription of anticoagulation and antiarrhythmic therapy in 90% of individuals.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): NATIONAL COLLEGE OF FRENCH CARDIOLOGISTS

Extended, standard, or De-escalation antiplatelet therapy for patients with coronary artery disease undergoing percutaneous coronary intervention? A trial-sequential, bivariate, influential, and network meta-analysis

AIMS

The relative safety and efficacy of de-escalation, extended duration (ED) (&gt;12-months), and standard dual antiplatelet therapy for 12-months (DAPT-12) in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) remains controversial.

METHODS AND RESULTS

Online databases were queried to identify relevant randomized control trials (RCTs). ED-DAPT, high-potency (HP) DAPT, shorter duration (SD) DAPT, and low-dose (LD) DAPT were compared with DAPT-12. A trial sequential, bivariate, influential, and frequentist network meta-analysis (NMA) was performed to determine the pooled estimates. A total of 30 RCTs comprising 81 208 (40 839 experimental, 40 369 control arm) patients with CAD were included in the quantitative analysis. On NMA, compared with DAPT-12, all types of de-escalation, HP-DAPT-12, and ED-DAPT strategies had a statistically non-significant difference in the incidence of MACE at a median follow-up of 1-year. Similarly, there was no significant difference in the incidence of stroke, stent thrombosis, target lesion revascularization (TLR), target vessel revascularization (TVR), and all-cause mortality between DAPT-12 and all other strategies. The network estimates showed a significantly lower incidence of major bleeding with DAPT for 3-months followed by P2Y12-inhibitor monotherapy (RR 0.62, 95% CI 0.45-0.84), while a higher risk of bleeding with HP-DAPT for 12 months (RR 1.55, 95% CI 1.16-2.06). The net clinical benefit and rankograms also favoured DAPT-3 (P2Y12) and discouraged the use of HP-DAPT-12 and ED-DAPT. A subgroup analysis of 19 RCTs restricted to patients who presented with acute coronary syndrome (ACS) mirrored the findings of pooled analysis. A sensitivity analysis revealed no influence of any individual study or individual strategy on net ischemic estimates. The trial sequential analysis (TSA) illustrated a consistently non-significant difference at the interim analysis of trials, reaching the futility area for MACE, while the cumulative Z-values line surpassed the monitoring boundary as well as the required information size for major bleeding favouring de-escalation strategy.

CONCLUSION

DAPT for three months followed by ticagrelor-only and use of aspirin + clopidogrel after a short period of high potency DAPT appears to be a safe strategy for treating post-PCI patients. However, given the methodological limitations and inclusion of a small number of trials in novel de-escalation strategies, these findings need validation by future large scale RCTs.

Atrial fibrillation detection with long-term continuous Holter ECG recording in patients with high cardiovascular risk and clinical palpitations: the prospective after study

AIM

New technologic tools for continuous ECG monitoring have been developed to detect and treat atrial fibrillation (AF) in specific populations with high cardiovascular risk. We evaluated the prevalence and the management of AF diagnosed in patients with high cardiovascular risk and non-documented clinical palpitation undergoing systematic 14-day continuous ECG-Holter monitoring.

METHODS

Patients were prospectively enrolled from December 2019 to December 2021 in this multicentre study, sponsored by the French National College of Cardiology. Patients met the following criteria: CHA₂DS₂VASc score ≥ 2 in males and ≥ 3 in females and clinical palpitations without previously documented arrhythmia. Enrolled patients underwent a continuous 14-day Holter-ECG monitoring for arrhythmia detection.

RESULTS

Among the 336 included patients, 39% were male, 75% were greater than 65 years of age and 46.5% had suffered a prior stroke. AF was detected in 14% of patients, among which 23.4% were detected in the first 24 h of monitoring. Finally, age ≥ 65 years (p = 0.037) was significantly associated with AF, as well as male gender (p = 0.023) and a lower rate of antiplatelet therapy (p = 0.018). Patients with diagnosed AF had a prescription of anticoagulation therapy in 90%. Antiarrhythmic drugs were administered in 90% of AF patients and 13% underwent AF ablation.

CONCLUSIONS

The systematic AF screening of patients with palpitations and high cardiovascular risk resulted in a diagnostic yield of AF in 14% of the population with a 14-day continuous ECG-Holter monitor. This strategy resulted in the prescription of anticoagulation and antiarrhythmic therapy in 90% of the AF detected population.

ESC/EAS guidelines for the detection, prevention, and treatment of individuals at risk of a first myocardial infarction: effect of 5 years of updates and the new SCORE2

Aims

The European Society of Cardiology (ESC) has released three consecutive guidelines within 5 years addressing cardiovascular prevention, risk scores, and cholesterol treatment. This study aims to evaluate whether the 2021 ESC guidelines improved the eligibility of individuals for primary prevention statin therapy before their first ST-segment elevation myocardial infarction (STEMI), and for intensive lipid-lowering treatments in secondary prevention.

Methods and results

The cardiovascular risk category of 2757 consecutive individuals admitted for a first STEMI was evaluated to assess whether they would have been eligible for primary prevention statins according to 2021 vs. 2019 and 2016 ESC guidelines. Eligibility for intensive lipid-lowering therapy in secondary prevention was assessed according to the real-life follow-up low-density lipoprotein cholesterol (LDL-C) and the expected follow-up LDL-C. More individuals would have been eligible for primary prevention statins according to 2021 and 2019 vs. 2016 guidelines (61.8% vs. 38.7% vs. 23.6%, P &lt; 0.01), a finding observed in both men (62.3% vs. 35.0% vs. 24.9%, P &lt; 0.01) and women (60.2% vs. 50.7% vs. 19.3%, P = 0.18). Only 27% of individuals reached the LDL-C objective of 55 mg/L in secondary prevention: using the ESC stepwise approach, 61.7% were eligible for higher doses of statins, 26.2% for ezetimibe, and 12.1% for a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (PCSK9i). Based on expected LDL-C reductions, eligibility for a PCSK9i in secondary prevention was greater with 2021 vs. 2016 guidelines (44.5% vs. 22.5%, P &lt; 0.01).

Conclusion

The 2021 ESC guidelines improved the detection and treatment of individuals at risk for a first myocardial infarction. In secondary prevention, 70% of patients kept LDL-C levels above 55 mg/dL: increasing the statin dose and adding ezetimibe were the most frequently recommended therapeutic actions.

Low levels of low-density lipoprotein cholesterol, intracerebral haemorrhage, and other safety issues: is there still a matter of debate?

Although some observational studies suggest a potential association of low levels of low-density lipoprotein cholesterol (LDL-C) with intracerebral haemorrhage (ICH), these analyses have issues of confounding where other factors (e.g. older age, frailty) that likely explain the findings, and the number of events was very low. More recent results from randomized clinical trials have not found an increased risk in ICH, most notably trials using PCSK9 inhibitors that achieve very low levels of LDL-C, but also in the long-term follow-up of the IMPROVE-IT trial. Also, other statin-associated safety issues, including new onset diabetes and the cancer risk should not be the reason of statin discontinuation, especially for the former, the benefits highly outweigh the risk (even 5×), and for the latter, there is no confirmed link suggesting any increased risk, in opposite, data exist suggesting benefits of statin therapy in cancer prevention. Furthermore, use of intensive lipid-lowering strategies with statins and non-statin drugs leads to decrease of ischaemic major adverse cardiac events, without safety concern, in a large population of patients with atherosclerotic cardiovascular disease (ASCVD). These data should promote the concept ‘the earlier, the lower, the longer, the better’ for the lipid management of patients with ASCVD. While few uncertainties remain in several populations that have been underrepresented in clinical trials (African American and Asian patients, low weight individuals), the most recent data with intensive LDL-C lowering with PCSK9 inhibitors are reassuring that the benefit outweighs any possible risk.

Use of IMMPACT Recommendations to Explore Pain Phenotypes in People with Knee Osteoarthritis

OBJECTIVE

Knee osteoarthritis (OA) is a disease of multiple phenotypes of which a chronic pain phenotype (PP) is known. Previous PP studies have focused on one domain of pain and included heterogenous variables. We sought to identify multidimensional PPs using the IMMPACT recommendations and their relationship to clinical outcomes.

METHODS

Participants >40 years of age with knee OA having a first-time orthopaedic consultation at five university affiliated hospitals in Montreal, Quebec and Hamilton (Canada) were recruited. Latent profile analysis was used to determine PPs (classes) using variables recommended by IMMPACT. This included pain variability, intensity and qualities, somatization, anxiodepressive symptoms, sleep, fatigue, pain catastrophizing, neuropathic pain, and quantitative sensory tests. We used MANOVA and Chi-square tests to assess differences in participant characteristics across the classes and linear and Poisson regression to evaluate the association of classes to outcomes of physical performance tests, self-reported function and provincial healthcare data.

RESULTS

343 participants were included (mean age 64 years, 64% female). Three classes were identified with increasing pain burden (class3 > class1), characterized by significant differences across most self-report measures and temporal summation, and differed in terms of female sex, younger age, lower optimism and pain self-efficacy. Participants in class2 and class3 had significantly worse self-reported function, stair climb and 40m walk tests, and higher rates of healthcare usage compared to those in class1.

CONCLUSIONS

Three distinct PPs guided by IMMPACT recommendations were identified, predominated by self-report measures and temporal summation. Using this standardized approach may improve PP study variability and comparison.

Comparing benefits from sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists in randomized clinical trials: a network meta-analysis

INTRODUCTION

Glucagon-like peptide 1 receptor agonists (GLP1-RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) were individually proven to reduce major adverse cardiovascular events (MACE) in type 2 diabetes mellitus (T2DM) patients, but the relative magnitude of benefits from these two drug classes is debated. We aimed to review current available data on GLP1-RA and SGLT2i in T2DM patients and compare their efficacy and safety in this population.

EVIDENCE ACQUISITION

We systematically searched MEDLINE/PubMed, the Cochrane Library, Google Scholar, Embase, www.tctmd.com, www.clinicaltrials.gov, www.clinicaltrialresults.org, from inception to September 17, 2020 for randomized controlled trials (RCTs) comparing the effects of GLP1-RA vs SGLT2i vs optimal medical therapy (OMT) in adult T2DM patients. Three authors independently screened references and extracted data using a predefined data collection form. Outcomes were analyzed using an indirect comparison meta-analysis of aggregate study-level data. The primary combined efficacy outcome comprised cardiovascular death, nonfatal myocardial infarction (MI), or nonfatal stroke. Secondary efficacy outcomes included all-cause mortality, cardiovascular mortality, non-fatal MI, non-fatal stroke, heart failure hospitalizations (HFH), and worsening renal function (WRF).

EVIDENCE SYNTHESIS

11 RCTs enrolling a total of 98572 patients were included; 56004 (57%) patients were derived from GLP1-RA RCTs and 42568 (43%) from SGLT2i RCTs. At a median follow-up of 3.0±1.3 years, compared with OMT, both GLP1-RA and SGLT2i similarly reduced the rate of the composite primary outcome (risk ratio [RR] 0.88; 95% confidence interval [95%CI] 0.83-0.93 and RR 0.88, 95%CI 0.82-0.95, respectively) with no difference between the drug classes (RR 1.00, 95%CI 0.92-1.10). Both classes similarly reduced MI rate, cardiovascular and all-cause mortality compared with OMT; stroke reduction was only observed with GLP1-RA with no difference in the indirect comparison with SGLT2i; conversely, only SGLT2i were effective in preventing HFH. Both GLP1-RA and SGLT2i were protective against WRF, with a major efficacy of SGLT2i in the indirect comparison.

CONCLUSIONS

This meta-analysis report that GLP1-RA and SGLT2i reduced with a similar efficacy not only MACE as MI, but also cardiovascular mortality and all-cause mortality at a median 3 years follow-up. SGLT2i were more protective in HFH and WRF than GLP1RA. These new data highlight the efficacy of SGLT2i not only in HF and chronic kidney disease (CKD) but also in ischemic heart diseases (IHD), with a homogeneity among the class, whereas the results observed with GLP1-RA are heterogenous. These findings will help clinical's decisions to optimize therapeutic strategies for diabetic patients.

Post-discharge and long-term follow-up after an acute coronary syndrome: International Collaborative Group of CNCF position paper

INTRODUCTION

Long-term follow-up after an acute coronary syndrome (ACS) presents a crucial challenge due to the high residual cardiovascular risk and the potential for major bleeding events. Although several treatment strategies are available, this article focuses on patients who have undergone percutaneous coronary intervention (PCI) for ACS, which is a frequent clinical situation. This position paper aims to support physicians in daily practice to improve the management of ACS patients.

MATERIAL AND METHODS

A group of recognized international and French experts in the field provides an overview of current evidence-based recommendations - supplemented by expert opinion where such evidence is lacking - and a practical guide for the management of patients with ACS after hospital discharge.

RESULTS

The International Collaborative Group underlines the need of a shared collaborative approach, and a care plan individualized to the patient's risk profile for both ischaemia and bleeding. Each follow-up appointment should be viewed as an opportunity to optimize the personalized approach, to reduce adverse clinical outcomes and improve quality of life. As risks - both ischaemic and haemorrhagic - evolve over time, the risk-benefit balance should be assessed in an ongoing dynamic process to ensure that patients are given the most suitable treatment at each time point.

CONCLUSIONS

This Expert Opinion aims to help clinicians with a practical guide underlying the proven strategies and the remaining gaps of evidence to optimize the management of coronary patients.

Women and Diabetes: Preventing Heart Disease in a New Era of Therapies

Despite major advances in cardiovascular research over the past decade, women with type 2 diabetes have a high risk of cardiovascular events. Several factors contribute to the poor prognosis for women, including higher levels of frailty and comorbidities, but their cardiovascular risk is underestimated and there is suboptimal implementation and uptitration of new evidence-based therapies, leading to high morbidity and mortality. Recent studies highlight the need for better management of diabetes in women that can be pursued and achieved in light of recent results from randomised controlled trials demonstrating evidence of the benefits of new therapeutic strategies in improving cardiovascular outcomes and quality of life of women covering the entire cardiovascular continuum. This review critically discusses the multiple benefits for women of new pharmacological treatments, such as glucagon-like peptide-1 receptor agonists, sodium–glucose cotransporter type 2 inhibitors (SGLT2i), proprotein convertase subtilisin/kexin type 9 inhibitors, inclisiran, icosapent ethyl and bempedoic acid in preventing cardiovascular events, and treatments, such as angiotensin receptor neprilysin inhibitors, SGLT2i, vericiguat and omecamtiv mecarbil, for preventing heart failure.

NSTE-ACS ESC Guidelines Recommend Prasugrel as the Preferred P2Y12 Inhibitor: A Contrarian View

In the 2020 European Society of Cardiology guidelines on non-ST-segment elevation acute coronary syndromes (NSTE-ACS), the experts proposed to put an end to the equipoise of ticagrelor and prasugrel in addition to aspirin in patients with NSTE-ACS who proceed to percutaneous coronary intervention (PCI). They gave a strong level of recommendation (IIa) in favor of prasugrel over ticagrelor in these patients. We challenge this proposition, which was mainly driven by the results of ISAR-REACT 5, an open-label prospective head-to-head study of a prasugrel-based strategy compared with a ticagrelor-based strategy in patients with ACS undergoing PCI. In addition to the methodological concerns regarding the ISAR-REACT 5 study, we also question this decision in light of the ISAR-REACT 5 diabetes mellitus subgroup analysis and previous studies and meta-analysis that showed no difference between ticagrelor and prasugrel in patients with ACS. Although we agree with the "one size does not fit all" concept for antiplatelet regimens in patients with ACS who proceed to PCI, we believe that the decision to strongly favor prasugrel was premature and not supported enough by the ISAR-REACT 5 results. In our opinion, equipoise remains between the ticagrelor- and prasugrel-based strategies and more data are needed to settle the debate.

Diagnosis and management of heart failure from hospital admission to discharge: A practical expert guidance

Heart failure (HF) has high event rates, mortality, and is challenging to manage in clinical practice. Clinical management is complicated by complex therapeutic strategies in a population with a high prevalence of comorbidity and general frailty. In the last four years, an abundance of research has become available to support multidisciplinary management of heart failure from within the hospital through to discharge and primary care as well as supporting diagnosis and comorbidity management. Within the hospital setting, recent evidence supports sacubitril-valsartan combination in frail, deteriorating or de novo patients with LVEF≤40%. Furthermore, new strategies such as SGLT2 inhibitors and vericiguat provide further benefit for patients with decompensating HF. Studies with tafamidis report major clinical benefits specifically for patients with ATTR cardiac amyloidosis, a remaining underdiagnosed and undertreated disease. New evidence for medical interventions supports his bundle pacing to reduce QRS width and improve haemodynamics as well as ICD defibrillation for non-ischemic cardiomyopathy. The Mitraclip reduces hospitalisations and mortality in patients with symptomatic, secondary mitral regurgitation and ablation reduces mortality and hospitalisations in patients with paroxysmal and persistent atrial fibrillation. In end-stage HF, the 2018 French Heart Allocation policy should improve access to heart transplants for stable, ambulatory patients and, mechanical circulatory support should be considered to avoid deteriorating on the waiting list. In the community, new evidence supports that improving discharge education, treatment and patient support improves outcomes. The authors believe that this review fills the gap between the guidelines and clinical practice and provides practical recommendations to improve HF management.

How to fill the GAPS-I in secondary prevention: application of a strategy based on GLP1 analogues, antithrombotic agents, PCSK9 inhibitors, SGLT2 inhibitors and immunomodulators

The continuous progress in cardiovascular (CV) risk prevention strategies has led to an impressive reduction in mortality and recurrent ischemic events in patients with coronary artery disease (CAD). However, the control of several CV risk factors remains suboptimal in many CAD patients, with a high rate of recurrent events, underlying the need for more new prevention strategies. The GAPS-I (GLP1 analogues, Antithrombotic agents, PCSK9 inhibitors, SGLT2 inhibitors and Immunomodulators) strategy offers a promising potential in patients with a high-residual CV risk, who are frequently encountered in daily practice, by offering an individualised and structured approach to addressing their individual risk factors. The current review summarises the evidence to date on each of its components, with respect to clinical outcomes and economic feasibility. The current evidence points to an efficacy of GAPS-I in reducing MACE and mortality, without a compromise on safety, albeit with the need for longer follow-up data. Key Points: - Secondary prevention remains suboptimal in many CAD patients, highlighting the need for innovative prevention strategies. - The present review discusses the current evidence on efficacy of the GAPS-I strategy in reducing MACE and mortality in patients with CAD. - The GAPS-I strategy, if widely adopted, provides a promising potential to assist cardiologists in managing patients at a heightened risk for further CV events.

New anti-diabetic agents: major advances with unanswered questions

No abstract present.

Proposal for a standardized discharge letter after hospital stay for acute myocardial infarction

In patients admitted for acute myocardial infarction, the communication and transition from specialists to primary care physicians is often delayed, and the information imparted to subsequent healthcare providers (HCPs) may be sub-optimal. A French group of cardiologists, lipidologists and diabetologists decided to establish a consensus to optimize the discharge letter after hospitalization for acute myocardial infarction. The aim is to improve both the timeframe and the quality of the content transmitted to subsequent HCPs, including information regarding baseline assessment, procedures during hospitalization, residual risk, discharge treatments, therapeutic targets and follow-up recommendations in compliance with European Society of Cardiology guidelines. A consensus was obtained regarding a template discharge letter, to be released within two days after patient’s discharge, and containing the description of the patient’s history, risk factors, acute management, risk assessment, discharge treatments and follow-up pathway. Specifically for post acute MI patients, tailored details are necessary regarding the antithrombotic regimen, lipid-lowering and anti-diabetic treatments, including therapeutic targets. Lastly, the follow-up pathway needs to be precisely mentioned in the discharge letter. Additional information such as technical descriptions, imaging, and quality indicators may be provided separately. A template for a standardized discharge letter based on 8 major headings could be useful for implementation in routine practice and help to improve the quality and timing of information transmission between HCPs after acute MI.

Meta-Analysis Comparing the Safety and Efficacy of Prasugrel and Ticagrelor in Acute Coronary Syndrome

Prasugrel and ticagrelor are preferred over clopidogrel for patients with acute coronary syndrome who underwent percutaneous coronary intervention. We sought to determine the relative merits of 1 agent over the other. Multiple databases were queried to identify relevant randomized control trials (RCTs) and observational cohort studies. Random-effects model was used to calculate an unadjusted odds ratio (OR) for major adverse cardiovascular and cerbrovascular events (MACCE) and its components. A total of 27 (7 RCTs, 20 observational cohort studies) studies comprising 118,266 (prasugrel 62,716, ticagrelor 51,196) patients were included. At 30 days, prasugrel was associated with a significantly lower odds of MACCE (OR 0.75, 95% confidence interval [CI] 0.67 to 0.85, p ≤0.0001) and mortality (OR 0.65, 95% CI 0.59 to 0.71, p ≤0.0001). At 1 year, the overall odds of mortality favored prasugrel (OR 0.79, 95% CI 0.68 to 0.92, p = 0.002), but no significant interdrug difference was seen in terms of MACCE (OR 0.89, 95% CI 0.76 to 1.05, p = 0.16). There was no significant difference in the odds of overall myocardial infarction, revascularization, stent thrombosis, stroke, and major bleeding events between the 2 groups on both 30-day and 1-year follow-up. A subgroup analysis of RCTs data showed no significant difference between prasugrel and ticagrelor in terms of any end point at all time points. In conclusion, prasugrel might have lower odds of MACCE and mortality at 30 days. However, there was no difference in the safety and efficacy end points of 2 drugs at 1 year. The observed transient prasugrel-related mortality benefits were subject to the bias of nonrandomized assignment.

2019 ESC/EAS Guidelines for management of dyslipidaemia: strengths and limitations

In 2019, the European Society of Cardiology and European Atherosclerosis Society released a new guideline document with substantial changes regarding the assessment of cardiovascular risk and treatments. The update of high-risk criteria and categories led to a better detection and primary prevention of patients at risk of a first cardiovascular event. Nonetheless, additional efforts are needed for a better inclusion of risk modifiers, especially specific to women, to improve risk stratification and direct primary prevention. Eventually, we discuss how these new guidelines implement PCSK9 inhibitors for very high-risk individuals and the evidence supporting new low-density lipoprotein cholesterol goals below, such as 55 and 40 mg/dL.