Secondary Prevention In Patients Research Articles

Efficacy of combination therapy with statin and ezetimibe versus high dose statin monotherapy in secondary prevention in high-risk patients

Abstract Background Secondary prevention in patients with acute coronary syndrome focuses on lowering low-density lipoprotein (LDL) cholesterol below 55 mg/dL. In all statin-naïve patients at high risk (LDL-cholesterol target <55 mg/dL), initiation of high-intensity statin monotherapy is recommended by ESC guidelines. Nonetheless, at one month, a significant proportion of patients do not reach their LDL-cholesterol target. Purpose The aim of this study was to compare lipid-lowering therapy with statin monotherapy versus statin with ezetimibe in secondary prevention in patients at high risk. Methods The current prospective study included 264 consecutive patients admitted with acute ST elevation myocardial infarction who underwent percutaneous coronary intervention. None of the patients had taken lipid-lowering drugs in the previous 12 months. Patients were randomly assigned to one of two treatment groups: Group 1 - rosuvastatin 40 mg (n= 144) and Group 2 - rosuvastatin 40 mg and ezetimibe 10 mg (n= 120). All patients' lipid profiles were assessed upon admission and after one month of lipid-lowering treatment. Results At baseline, no patient had LDL cholesterol level lower than 55 mg/dL. There was no significant difference in lipid profile at baseline between the two groups (all p > 0.05). No differences were observed between the two groups in terms of baseline LDL-cholesterol deviation from the target (103.4% versus 99.70%; p= 0.66). As expected, the combination therapy reduced LDL-cholesterol at one month significantly higher compared to high-dose statin monotherapy (-59.65% versus -37.54%; p< 0.0001). After one month of treatment, only 47.92% of patients in Group 1 reached the LDL-cholesterol target (<55 mg/dL) compared to 90.00% of the patients in Group 2 (p<0.0001; R.R.= 0.53). Conclusion(s) Our findings show that statin and ezetimibe combination therapy is more effective in reduction in LDL-cholesterol levels and reaching targets compared to statin monotherapy alone. In statin-naïve patients at high risk, early initiation of the statin and ezetimibe combination instead of statin monotherapy should be taken into account in secondary prevention, for an earlier reach of the LDL-cholesterol target and to reduce the overall cardiovascular risk.

Efficacy of lipid lowering therapy beyond statins to prevent cardiovascular events

Abstract Background Lipid lowering therapy is a key cornerstone in secondary prevention of patients with coronary artery disease. However, only a minority of patients with statin therapy reach LDL thresholds as suggested by the ESC. Ezetimibe, bempedoic acic, and proprotein convertase subtilisin/kexin type 9 (PCSK-9) (synthase-) inhibitors allow for the reduction in LDL-cholesterol in addition to statin therapy. Purpose We aimed to perform a meta-analysis of existing trials, evaluating how lipid lowering therapy beyond statins impacts cardiovascular outcome. In specific, we evaluated the potential influence of duration of follow-up on the association with mortality endpoints. Methods We performed a systematic search using the Pubmed, Cochrane, SCOPUS, and Web of Science databases for studies, evaluating the impact of an intensified lipid lowering therapy via ezetimibe, bempedoic acid, Bococizumab, Alirocumab, Evolocumab, Inclisiran in addition to statin therapy compared to statin therapy alone. Manuscript and congress presentations, published until 1st of August 2023, were included. We made our search specific and sensitive using Medical Subject Headings terms and free text and considered studies published in English language. Search terms used were : "Bempedoic Acid" or "Bococizumab" or "Alirocumab" or "Evolocumab" or "Ezetimibe" or "Inclisiran" and "statin" and "cardiovascular events". Results A total of 123,785 patients from 15 randomized controlled trials (IMPROVE-IT, FOURIER, ODYSSEY Outcomes, ODYSSEY LONG TERM, EWTOPIA 75, PACMAN-AMI, RACING, SIPRE I, SPIRE II, OSLER-1 and OSLER-2, CLEAR HARMONY, CLEAR OUTCOMES, CLEAR SERENITY, CLEAR WISDOM) were included. Treatment with ezetimibe or a PCSK-9 inhibitor was associated with a 19% risk reduction in cardiovascular events (OR [95%CI]: 0.81 [0.75; 0.86]). Effect sizes were similar for myocardial infarction (0.81 [0.74; 0.89]) and even more pronounced for ischemic stroke (0.77 [0.70; 0.84]). In contrast, all-cause mortality was not improved by the intensified lipid lowering therapy (0.99 [0.93; 1.04]). Stratifying by follow-up duration of < vs. ≥ 3 years, no improvement in all-cause mortality was observed in both groups (<3 years: 1.04 [0.93; 1.17]; ≥3 years: 0.97 (0.88; 1.06). No relevant heterogeneity and inconsistency between groups was present in all analyses (detailed data not shown). Conclusion Intensified LDL-lowering therapy with ezetimibe, bempedoic acic or PCSK-9 inhibitors, in addition to statins, reduces the risk of myocardial infarction and stroke, however, does not impact overall mortality. A potential survival benefit was also not observed in studies with follow-up duration of ≥ 3 years.

Clopidogrel versus aspirin monotherapy for secondary prevention after percutaneous coronary intervention - a nationwide population-based study

Abstract Background After percutaneous coronary intervention (PCI), patients are maintained on single antiplatelet therapy (SAPT) for secondary cardiovascular prevention after completing the guideline-recommended duration of DAPT for a period of time. We sought to compare the efficacy and safety of clopidogrel versus aspirin monotherapy for secondary prevention in patients who undergoing PCI in a population-based cohort study using the database from the National Health Insurance Service (NHIS) in Korea. Methods Of those who underwent PCI from 2009 to 2020, 133,343 patients were selected for analysis. (aspirin 65,802 patients, clopidogrel 67,653 patients). To balance between aspirin and clopidogrel users for the comparison of efficacy and safety, we applied the inverse probability of treatment weighting (IPTW) of propensity score method. The primary effectiveness outcome was major cardiovascular events (MACEs) as the composite of cardiovascular death, myocardial infarction (MI) or stroke. The primary safety outcome was any bleeding. We divided the short DAPT user (< 6 months of DAPT in patients with CCS or < 12 months of DAPT in patients with ACS) and long DAPT user (≥ 6 months of DAPT in patients with CCS or ≥ 12 months of DAPT in patients with ACS) by DAPT duration. Results After IPTW matching, overall the mean age of participants was 63.8±16.3 and the median SAPT duration was 3.3 (1.3 – 6.2). During period, the overall primary effectiveness outcome occurred in 4.1% in aspirin group and 2.8% in clopidogrel group (hazard ratio [HR], 0.684; 95% CI, 0.656 – 0.712; p-value <0.0001) (Figure 1-A). the overall primary safety outcome occurred in 2.4% in aspirin group and 2.1% in clopidogrel group (HR, 0.945; 95% CI, 0.899 – 0.994; p-value, 0.0287) (Figure 1-B). In short DAPT group, clopidogrel reduced the risk of MACE (HR, 0.761; 95% CI, 0.715 – 0.811; p-value, <0.0001) but did not reduce the risk of bleeding (HR, 0.973; 95% CI, 0.893 – 1.056; p-value, 0.5067) comaped with aspirin. However, in the long DAPT group, clopdiogrel reduced both MACE (HR, 0.633; 95% CI, 0.600 – 0.669; p-value <0.0001) and bleeding risk (HR, 0.931; 95% CI, 0.873 – 0.992; p-value, 0.028) compared with aspirin. (Figure 2) Conclusion Clopidogrel monotherapy, compared with aspirin monotherapy during the chronic maintenance period after PCI reduced the risk of MACEs and bleeding. As shown in randomized controlled trials, clopidogrel monotherapy was superior to aspirin monotherapy in preventing future clinical adverse events in real-world bid database.

Impact of measured or calculated small dense LDL cholesterol compared with apolipoprotein B or non-HDL cholesterol for long-term secondary prevention in patients with stable coronary artery disease

Abstract Background This study was aimed to investigate whether directly measured small dense low-density lipoprotein cholesterol (D-sdLDL-C) can predict long-term coronary artery disease (CAD) events compared with LDL-C, non–high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (apoB), and estimated sdLDL-C (E-sdLDL-C) determined by Sampson’s equation in patients with stable CAD. Methods D-sdLDL-C measured at Showa University, and E-sdLDL-C were evaluated in 790 male and 244 female patients with stable CAD. CAD events defined as sudden cardiac death, onset of acute coronary syndrome, and/or need for coronary revascularization were monitored for 12 years. Cut-points of D-sdLDL-C, E-sdLDL-C, LDL-C, non-HDL-C, and apoB were determined by receiver operating characteristic curves. Results CAD events were observed in 238 male and 67 female patients. The Kaplan–Meier event-free survival curves showed that patients with D-sdLDL-C ≥32.1 mg/dL had an increased risk for CAD events (chi-square from log-rank test = 7.23), whereas risk in patients with E-sdLDL-C ≥36.2 mg/dL was not. In the group with high D-sdLDL-C, the multivariable-adjusted hazard ratio (HR) was 1.47, 95% confidence interval (CI) 1.15-1.89, and it remained significant after adjustment for LDL-C, non-HDL-C, or apoB. These results remained significant in the patients treated with statin. HRs for high LDL-C, non-HDL-C, or apoB were not statistically significant after adjustment for high D-sdLDL-C. The high D-sdLDL-C enhanced risk of high LDL-C, non-HDL-C, and apoB (HR 1.73, 95%CI 1.27-2.37). Conclusions: High D-sdLDL-C can predict long-term recurrence of CAD in stable CAD patients independently of apoB and non-HDL-C by distinguishing the patients at high risk. D-sdLDL-C is an independent risk-enhancer for secondary CAD prevention whereas E-sdLDL-C is not.Figure

Predictor of wasted implantable cardioverter defibrillator for secondary prevention

Abstract Background ICD is the first line treatment to prevent sudden cardiac death from recurrence of VT/VF. However, patients with organic heart disease have many comorbidities, and some patients die without history of appropriate ICD therapy in lifetime. Purpose The aim of this study is to examine the predictors of death without appropriate ICD therapy in lifetime, among ICD patients for secondary prevention with organic heart disease. Methods We enrolled consecutive patients implanted with ICD/CRT-D for secondary prevention between 2000 and 2022. We excluded patients without organic heart disease, and alive patients without history of appropriate ICD therapy. Inappropriate candidate (Wasted-group) for defibrillator was defined as the patient who died without history of appropriate ICD therapy or died within one year from appropriate ICD therapy. Appropriate candidate (Appropriate-group) was defined as the patient who had been alive over one year from appropriate ICD therapy (Wasted-group:36, Appropriate-group:131). Results During a follow-up of 8.3 ± 5.3 years, a total of 93 (56%) patients died, including 6 (4%) patients died within one year from ICD/CRT-D implantation. Among the 36 patients of Wasted-group, 28 patients died without history of appropriate ICD therapy. Higher age, ischemic cardiomyopathy, non-ARVC, a past history of VF, diabetes mellitus, and higher serum creatinine was the predictor of Wasted-group (P<0.05). Wasted ICD risk score was constructed with the summation of these predictors for predicting candidates of Wasted-group. When the Wasted ICD risk score was ≥3, positive predictive value and negative predictive value were 39.7% and 89.4%, respectively (AUC=0.77, P<0.001). Conclusion Patients with a Wasted ICD risk score <3 is likely to receive appropriate ICD therapy in lifetime. Therefore, Wasted ICD risk score might be useful to decide to need for ICD therapy, regarding elderly patients who would be hesitant to have ICD implanted.Wasted ICD risk score

Risk for appropriate ICD intervention and complications in patients implanted after an out-hospital cardiac arrest compared to patients implanted for primary and other secondary prevention indication

Abstract Background Few data are available about patients implanted with an implantable cardioverter defibrillators (ICDs) after an out-of-hospital cardiac arrest (OHCA). In particular, it is unclear if these patients have a higher risk of appropriate device therapy than patients implanted for primary and other secondary prevention. Purpose To assess if appropriate device interventions (ATP/shocks) are higher in patients implanted after OHCA compared to patients implanted for primary and secondary prevention other than OHCA. To verify also if mortality, implantation-related complications (pneumothorax, hemothorax, hematoma, cardiac tamponade), device-related complications (lead displacement and fracture, infections) and inappropriate shocks/ATP are higher in OHCA patients compared to other patients. Methods This is a retrospective multicenter international study. All the patients implanted with an ICD between January 2015 and December 2016 in the participating centers were included. Follow-up was considered concluded in case of death or at the last follow-up available until December 2023. Patients were divided according to ICD implantation indication (secondary prevention after OHCA, other secondary prevention, primary prevention). Results 1386 patients (79% males; median age 67, IQR 59-74) from 15 centers were included with a median follow-up of 83 months: 111 patients in OHCA group, 134 in other secondary prevention group and 1141 in primary prevention group. Considering the first appropriate intervention, a significant difference among the three groups was observed (Fig.1A) and, at post-hoc comparison, the OHCA group was at higher risk than primary prevention (HR 1.51, 95%CI 1.06-2.17, p=0.02), but was at similar risk than other secondary prevention (HR 0.79, 95%CI 0.51-1.23, p=0.3). This was confirmed also after correction for age, gender, history of atrial fibrillation, aetiology and multi-comorbidity (Fig.2A). However, considering the number of appropriate interventions during follow-up, the risk of OHCA group was lower than other secondary prevention (IRR 0.28, 95%CI 0.11-0.68, p<0.01) and similar to primary prevention (IRR 0.97, 95%CI 0.47-1.96, p=0.93), also after correction for the other predictors (Fig.2B). The three groups showed no differences in survival (Fig.1B), implantation-related complication, device-related complications (Fig.1C) and inappropriate shocks/ATP. Conclusion Patients implanted with an ICD after an OHCA have a risk similar to those implanted for other secondary prevention, when considering the first appropriate intervention, but a risk similar to those implanted for primary prevention when considering the number of appropriate interventions during follow-up. Our study confirms that OHCA patients represents a peculiar population with the same chance of survival and rate of complications compared to primary and other secondary prevention patients suggesting the need of more studies to improve their long-term treatment.Figure 1 (Panel A, B and C)Figure 2 (Panel A and B)

Lower Perceived Social Support Associated With Greater Hopelessness in Patients After an Acute Ischemic Heart Disease Event.

Hopelessness is present in up 52% of patients with ischemic heart disease (IHD) and is associated with increased morbidity and mortality. Lower perceived social support (PSS) has been associated with greater hopelessness in a pilot study of patients with IHD reporting moderate-severe hopelessness but has not been examined in a larger sample reporting none-severe levels of hopelessness and while controlling for covariates. The aim of this study was to determine the relationship between PSS and hopelessness in patients with IHD. Using a cross-sectional design, 178 participants were enrolled while hospitalized for an IHD event at 1 large hospital in the United States. Data collection occurred 2 weeks after hospital discharge using the State-Trait Hopelessness Scale, ENRICHD Social Support Inventory, Patient Health Questionnaire-9, a demographic form, and a medical record abstraction form. Linear models were used to assess the association between variables in unadjusted models and models adjusted for demographic and medical history. Most participants were male (67%), married (67%), and non-Hispanic White (92%) and underwent coronary artery bypass surgery (61%). There was a moderate inverse correlation between PSS and state (r = -0.31, P < .001) and trait (r = -0.28, P < .001) hopelessness in unadjusted models. The relationships remained significant in adjusted models and did not differ by sex, type of IHD event, or marital status. Lower PSS was associated with greater hopelessness in patients with IHD. Assessing PSS and hopelessness during hospitalization for an IHD event may enable clinicians to provide targeted interventions to reduce risk of hopelessness and improve secondary prevention in patients with IHD.

Bicuspid Aortic Valve in Children and Young Adults for Cardiologists and Cardiac Surgeons: State-of-the-Art of Literature Review.

Bicuspid aortic valve disease is the most prevalent congenital heart disease, affecting up to 2% of the general population. The presentation of symptoms may vary based on the patient's anatomy of fusion, with transthoracic echocardiography being the primary diagnostic tool. Bicuspid aortic valves may also appear with concomitant aortopathy, featuring fundamental structural changes which can lead to valve dysfunction and/or aortic dilatation over time. This article seeks to give a comprehensive overview of the presentation, treatment possibilities and long-term effects of this condition. The databases MEDLINE, Embase, and the Cochrane Library were searched using the terms "endocarditis" or "bicuspid aortic valve" in combination with "epidemiology", "pathogenesis", "manifestations", "imaging", "treatment", or "surgery" to retrieve relevant articles. We have identified two types of bicuspid aortic valve disease: aortic stenosis and aortic regurgitation. Valve replacement or repair is often necessary. Patients need to be informed about the benefits and drawbacks of different valve substitutes, particularly with regard to life-long anticoagulation and female patients of childbearing age. Depending on the expertise of the surgeon and institution, the Ross procedure may be a viable alternative. Management of these patients should take into account the likelihood of somatic growth, risk of re-intervention, and anticoagulation risks that are specific to the patient, alongside the expertise of the surgeon or centre. Further research is required on the secondary prevention of patients with bicuspid aortic valve (BAV), such as lifestyle advice and antibiotics to prevent infections, as the guidelines are unclear and lack strong evidence.

Low-density Lipoprotein Cholesterol Reduction Therapies for Secondary Prevention in Patients with Stroke: A Network Meta-analysis.

Patients with previous strokes are at a higher risk of stroke recurrence. Current guidelines recommend a range of low-density lipoprotein cholesterol (LDL-C)-lowering treatments to reduce the risk of recurrent stroke. However, the optimal agent for decreasing LDL-C to lower the risk of recurrent stroke remains unclear. This study aimed to assess the relative effects of various LDL-C -lowering agents for secondary stroke prevention. Several databases were searched from inception up to 2022. Only randomized controlled trials that compared different LDL-C-lowering agents in adult patients with previous strokes were included. The primary endpoint was a recurrent stroke. The surface under the cumulative ranking curve (SUCRA) was also applied to estimate the overall ranking probability of the treatment agents for each outcome. Overall, nine trials comprising 17,226 patients were included. Ezetimibe plus statins (RR: 0.56, 95% CrI: 0.35-0.87) and statins alone (RR: 0.90, 95% CrI: 0.81-1.00) reduced the risk of stroke recurrence. Ezetimibe plus statins was superior to statins alone in decreasing the incidence of recurrent stroke (RR: 0.62, 95% CrI: 0.39-0.95). However, treatment with statins was related to an increased risk of hemorrhagic stroke compared to placebo (RR: 1.57, 95% CrI: 1.13-2.21). All agents were related to a decreased incidence of major adverse cardiovascular events. Treatment with ezetimibe plus statins was suggested as the most efficacious in decreasing the incidence of recurrent stroke. The analysis also revealed that statin monotherapy was related to an increased risk of hemorrhagic stroke.

Can CYP2C19 genotyping improve antiplatelet therapy efficacy in real-life practice? Recent advances.

Clopidogrel remains the most widely used P2Y₁₂ receptor inhibitor worldwide and is often used in combination with aspirin for secondary prevention in patients with arterial disease. The drug is associated with a wide response variability with one on three patients exhibiting little or no inhibition of adenosine diphosphate-induced platelet aggregation. It is a prodrug that is mainly metabolized by hepatic cytochrome P450 (CYP) 2C19. Patients who carry a CYP2C19 loss-of-function (LoF) allele have reduced metabolism of clopidogrel that is associated with reduced platelet inhibition compared to non-carriers that is associated with increased risk for thrombotic event occurrences, particularly, stent thrombosis. The United States Food and Drug Administration (US FDA) issued a black box warning in the clopidogrel label highlighting the importance of presence of CYP2C19 LOF allele during the insufficient metabolism of clopidogrel and availability of other potent P2Y₁₂ inhibitor for the treatment in CYP2C19 poor metabolizers. Clinical trials have conclusively demonstrated greater anti-ischemic benefits of prasugrel/ticagrelor in the treatment of patients carrying the CYP2C19 LoF allele. However, uniform use of these more potent P2Y₁₂ inhibitors has been associated with greater bleeding and cost, and lower adherence. The latter information provides a strong rationale for personalizing P2Y₁₂ inhibitor therapy based on the laboratory determination of CYP2C19 genotype. However, cardiologists have been slow to take up pharmacogenetic testing possibly due to lack of provider and patient education, clear cardiology guidelines and, and lack of positive results from adequately sized randomized clinical trials. However, current evidence strongly supports genotyping of patients who are candidates for clopidogrel. Physicians should strongly consider performing genetic tests to identify LoF carriers and treat these patients with more pharmacodynamically predictable P2Y₁₂ inhibitors than clopidogrel.

Low-dose colchicine for the prevention of cardiovascular events after percutaneous coronary intervention: Rationale and design of the COL BE PCI trial

Patients with coronary artery disease (CAD) remain vulnerable to future major atherosclerotic events after revascularization, despite effective secondary prevention strategies. Inflammation plays a central role in the pathogenesis of CAD and recurrent events. To date, there is no specific anti-inflammatory medicine available with proven effective, cost-efficient, and favorable benefit-risk profile, except for colchicine. Initial studies with colchicine have sparked major interest in targeting atherosclerotic events with anti-inflammatory agents, but further studies are warranted to enforce the role of colchicine role as a major treatment pillar in CAD. Given colchicine's low cost and established acceptable long-term safety profile, confirming its efficacy through a pragmatic trial holds the potential to significantly impact the global burden of cardiovascular disease.The COL BE PCI trial is an investigator-initiated, multicenter, double-blind, event-driven trial. It will enroll 2,770 patients with chronic or acute CAD treated with percutaneous coronary intervention (PCI) at 19 sites in Belgium, applying lenient in- and exclusion criteria and including at least 30% female participants. Patients will be randomized between 2 hours and 5 days post-PCI to receive either colchicine 0.5 mg daily or placebo on top of contemporary optimal medical therapy and without run-in period. All patients will have baseline hsCRP measurements and a Second Manifestations of Arterial Disease (SMART) risk score calculation. The primary endpoint is the time from randomization to the first occurrence of a composite endpoint consisting of all-cause death, spontaneous non-fatal myocardial infarction, non-fatal stroke, or coronary revascularization. The trial is event-driven and will continue until 566 events have been reached, providing 80% power to detect a 21 % reduction in the primary endpoint taking a premature discontinuation of 15% into account. We expect a trial duration of approximately 44 months.The COL BE PCI Trial aims to assess the effectiveness and safety of administering low-dose colchicine for the secondary prevention in patients with both chronic and acute coronary artery disease undergoing PCI. Trial registration: ClinicalTrials.gov: NCT06095765.

Rethinking the use of direct oral anticoagulants for secondary thromboprophylaxis in patients with thrombotic antiphospholipid syndrome.

Patients with thrombotic antiphospholipid syndrome (APS) are at high risk for recurrent thrombosis, and indefinite anticoagulation is recommended. Patients with APS merit indefinite anticoagulation, and vitamin K antagonists (VKAs) have historically been the standard treatment. Direct oral anticoagulants (DOACs) present an appealing alternative to VKAs. Due to their pharmacokinetic and pharmacodynamic characteristics, DOACs offer advantages over VKAs, namely the lack of need for laboratory monitoring, the usage of a fixed dosage, and the absence of significant interaction with dietary components and drugs. The efficacy and safety of DOACs in patients with APS have been studied in four phase II/III clinical trials (three with rivaroxaban and one with apixaban). These studies showed DOACs' inferiority compared to VKAs in preventing recurrent thrombosis. Recurrence was significantly greater in patients with arterial thrombotic events and a triple positivity for antiphospholipid antibodies. No differences were observed in the incidence of venous thromboembolism between both groups. Major bleeding was similar in patients treated with DOACs or VKAs. Several observational studies have reported similar results. This review aims to analyse the existing evidence on the efficacy and safety of DOACs for secondary prevention in patients with APS.

Implantable cardioverter defibrillator therapy in paediatric patients for primary vs. secondary prevention.

The decisions about placing an ICD in a child are more difficult than in an adult due to longer expected lifespan and the complication risk. Young patients gain the most years from ICDs, despite higher risk of device-related complications. The secondary prevention ICD indication is clear, and device is implanted regardless of potential complications. For primary prevention, risk of sudden cardiac death and complications need to be evaluated. We aimed to compare outcomes for primary and secondary prevention ICDs. Retrospective nationwide cohort study including paediatric patients identified from the Danish ICD registry with ICD implanted at an age ≤ 15 from 1982-21. Demographics, complications (composite of device-related infections or lead-failure requiring re-operation, mortality because of arrhythmia, or unknown cause), and mortality were retrieved from medical charts. Endpoint was appropriate therapy (shock or anti-tachycardia pacing for ventricular tachycardia or fibrillation). Of 72 receiving an ICD, the majority had channelopathies (n = 34) or structural heart diseases (n = 28). ICDs were implanted in 23 patients for primary prevention and 49 for secondary prevention, at median ages of 13.8 and 11.6 years (P-value 0.01), respectively. Median follow-up was 9.0 (interquartile ranges: 4.7-13.5) years. The 10-year cumulative incidence of first appropriate therapy was 70%, with complication and inappropriate therapy rates at 41% and 15%, respectively. No difference was observed between prevention groups for all outcomes. Six patients died during follow-up. In children, two-thirds are secondary prevention ICDs. Children have higher appropriate therapy and complication rates than adults, while the inappropriate therapy rate was low.

To be or not to be on: aspirin and coronary artery bypass graft surgery.

Aspirin's role in secondary prevention for patients with known coronary artery disease (CAD) is well established, validated by numerous landmark trials over the past several decades. However, its perioperative use in coronary artery bypass graft (CABG) surgery remains contentious due to the delicate balance between the risks of thrombosis and bleeding. While continuation of aspirin in patients undergoing CABG following acute coronary syndrome is widely supported due to the high risk of re-infarction, the evidence is less definitive for elective CABG procedures. The literature indicates a significant benefit of aspirin in reducing cardiovascular events in CAD patients, yet its impact on perioperative outcomes in CABG surgery is less clear. Some studies suggest increased bleeding risks without substantial improvement in cardiac outcomes. Specific to elective CABG, evidence is mixed, with some data indicating no significant difference in thrombotic or bleeding complications whether aspirin is continued or withheld preoperatively. Advancements in pharmacological therapies and perioperative care have evolved significantly since the initial aspirin trials, raising questions about the contemporary relevance of earlier findings. Individualized patient assessments and the development of risk stratification tools are needed to optimize perioperative aspirin use in CABG surgery. Further research is essential to establish clearer guidelines and improve patient outcomes. The objective of this review is to critically evaluate the existing evidence into the optimal management of perioperative aspirin in elective CABG patients.

Long-term consequences and secondary prevention in patients who suffered acute coronary syndrome in real clinical practice based on the results of a 12-year follow-up

Long-term consequences and secondary prevention in patients who suffered acute coronary syndrome in real clinical practice based on the results of a 12-year follow-up

Lipid Control and Medical Costs Among Patients With and Without Established Atherosclerotic Cardiovascular Disease Followed in a Brazilian Private Healthcare System.

There is limited real-world data of lipid control and healthcare costs among patients with and without Atherosclerotic Cardiovascular Disease (ASCVD) in Latin America. A retrospective cohort study including patients with LDL-cholesterol (LDL-C) assessment from 2015 to 2017 was performed in a health insurance database. Patient characteristics, comorbidities and laboratory data were collected, and International Classification of Diseases (ICD) codes were used to identify a subcohort of patients with ASCVD (secondary prevention) and assess the proportion of these patients with LDL-C controlled. Lipid control among patients without ASCVD (primary prevention) and healthcare costs in one year in the overall population were also assessed. From the 17,434 patients selected, 5,208 (29.8%) had ASCVD. The mean age of these patients in secondary prevention was 68.9 (±12.3) years and 47.8% were male patients. LDL-C < 70 mg/dL was identified in 19.1% of the ASCVD population and only 4.1% had an LDL-C < 50 mg/dL. LDL control was worse in women compared to men (13.1% vs. 25.7%; P < 0.01). The average cost in one year was 3,591 American dollars (USD) per patient in primary prevention compared to 8,210 dollars per year for patients in secondary prevention (P < 0.01). While outpatient costs accounted for 59.8% of the total cost in the primary prevention group, the main cost of the secondary prevention population was related to hospital costs (54.1%). Despite the favorable evidence for intensive cholesterol reduction, the evaluation of large real-world database with more than 17,000 individuals showed that the targets of guideline recommendations have not yet been adequately incorporated into clinical practice. Average annual cost per patient in secondary prevention is more than twice compared to primary prevention. Hospital expenses account for most of the cost in the secondary prevention group, while outpatient costs predominate in primary prevention.

PCSK9 inhibitors in real life-Cardiometabolic risk management in dyslipidemic patients in Vienna.

Proprotein convertase subtilisin kexin type9 (PCSK9) inhibitors have emerged as important therapeutic options for patients unable to achieve the low-density lipoprotein cholesterol (LDL‑C) target or to tolerate alternative lipid-lowering agents. The aim of this study was to investigate the efficacy of PCSK9 inhibitor treatment in tertiary routine care, by determining the percentage of patients reaching individual LDL‑C target levels 1 year after treatment initiation. Patients routinely started on PCSK9 inhibitors at our lipid clinic between 2017 and 2020 were retrospectively analyzed. Attainment of the LDL‑C target, utilization of follow-ups, cardiovascular events and effects on laboratory parameters were investigated. In this study 347 patients were included, with the majority managed in secondary prevention (94.5%). The LDL‑C target was achieved by 44.9% after ca. 14months, with differences between statin users and non-users (51.0% vs. 22.7%; p < 0.001). The median LDL‑C decreased from 126.00 mg/dL at baseline to 48 mg/dL (-61.6%; -77.00 mg/dL; p < 0.001) after ~2months and to 60 mg/dL (-52.9%; -59.00 mg/dL; p < 0.001) after ~14months. Median lipoprotein(a) levels decreased significantly from 184.0 nmol/L to 165.5 nmol/L (-25.9%; -25.5 nmol/L; p = 0.001) after ~2months, whereas no effects on creatine kinase, amylase and lipase were detectable. Of the patients 15% utilized 4follow-ups. The PCSK9 inhibitor intolerance occurred in 3.5% of patients. With the effect of LDL-lowering remaining constant over 14months, PCSK9 inhibitor treatment showed effective and sustainable LDL‑C lowering in amajority of patients in secondary prevention, bringing them closer to the recommended LDL‑C goal, particularly those under concomitant statin medication. Treatment with PCSK9 inhibitors appears to be well-tolerated, confirming data from clinical trials in real life.

Usefulness of the C2HEST score to predict new onset atrial fibrillation. A systematic review and meta-analysis on >11 million subjects.

The incidence of new-onset atrial fibrillation (NOAF) is increasing in the last decades. NOAF is associated with worse long-term prognosis. The C2HEST score has been recently proposed to stratify the risk of NOAF. Pooled data on the performance of the C2HEST score are lacking. Systematic review and meta-analysis of observational studies reporting data on NOAF according to the C2HEST score. We searched PubMed, Web of Science and Google scholar databases without time restrictions until June 2023 according to PRISMA guidelines. Meta-analysis of the area under the curve (AUC) with 95% confidence interval (95% CI) and a sensitivity analysis according to setting of care and countries were performed. Of 360 studies, 17 were included in the analysis accounting for 11,067,496 subjects/patients with 307,869 NOAF cases. Mean age ranged from 41.3 to 71.2 years. The prevalence of women ranged from 10.6 to 54.75%. The pooled analysis gave an AUC of .70 (95% CI .66-.74). A subgroup analysis on studies from general population/primary care yielded an AUC of 0.69 (95% CI 0.64-0.75). In the subgroup of patients with cardiovascular disease, the AUC was .71 (.69-.79). The C2HEST score performed similarly in Asian (AUC .72, 95% CI .68-.77), and in Western patients (AUC .68, 95% CI .62-.75). The best performance was observed in studies with a mean age <50 years (n = 3,144,704 with 25,538 NOAF, AUC .78, 95% CI .76-.79). The C2HEST score may be used to predict NOAF in primary and secondary prevention patients, and in patients across different countries. Early detection of NOAF may aid prompt initiation of management and follow-up, potentially leading to a reduction of AF-related complications.

INTERASPIRE a global cross-sectional survey of secondary prevention of cardiovascular disease (CVD) across six WHO regions

Abstract Introduction This survey of secondary prevention of CVD was conducted through National Societies of Cardiology across all WHO regions and included Kenya, Nigeria, Tanzania, Argentina, Colombia, Egypt, UAE, Poland, Portugal, Indonesia, China, Malaysia, Philippines and Singapore. Purpose The overall aim of INTERASPIRE was to assess the clinical implementation of risk reduction initiatives to reduce cardiovascular risk in line with lifestyle, risk factor and therapeutic targets defined in international and national guidelines on CVD prevention. Methods A consecutive sample of patients (&amp;gt; 18 and &amp;lt; 80 years) admitted to public hospitals in selected regions within each participating country with an acute ST elevation myocardial infarction (MI), Non-ST elevation MI, acute myocardial ischaemia or for elective revascularisation was identified retrospectively from medical record systems. Patients were invited to attend a clinical visit with trained research assistants at least 6 months but not more than 2 years after their event. The assessment included self-reported smoking status validated with an expired breath carbon monoxide measurement, self-reported participation in physical activity using the Godin validated questionnaire and standardised measurements of height, weight, blood pressure, blood lipids and blood glucose including an oral glucose tolerance test. Results 4548 (21.1% women) patients attended the clinical visit. 12.6% were smoking with wide variation across countries (1.9 – 27.3%). 48% of those who were smoking at the time of hospital admission had continued to smoke. 66.5% reported being sedentary with wide variation across countries (51.3 – 90.5%). 24% were obese and 40% centrally obese with a large difference between men (32.3%) and women (69.4%). 38% achieved a blood pressure target of &amp;lt; 130/80 mmHg, 19.2% achieved an LDL-C target of &amp;lt; 1.4 mmol/l and in patients with self-reported diabetes 56% achieved a target HbA1c of &amp;lt; 53 mmol/mol (7%). In those who did not report having diabetes, a further 9.8% had undetected diabetes and 26.9% impaired glucose tolerance. 48% were prescribed all four classes of cardioprotective drugs (antiplatelets, beta blockers, ACE/ARB, lipid lowering agents) with wide variation between countries (25% - 75%) and 88.3% were prescribed both antiplatelets and lipid lowering agents. Only 1219 (26.8%) were advised to attend cardiac rehabilitation with wide variation (4.5% to 58.9%) between countries. Overall only 9.0% (men 9.1%, women 9.1%) of all patients attended cardiac rehabilitation. Figure 1 shows the distribution of the INTERASPIRE Guideline Target Score. Conclusion There is substantial room for improvement in secondary prevention in patients with coronary disease globally. It is of concern that only 9% of patients received cardiac rehabilitation despite it being a Class 1 recommendation in all prevention guidelines with wide variation in advice and uptake between countries.Figure 1

Role of Cardiac Biomarkers in Stroke and Cognitive Impairment.

This topical review assesses the growing role of cardiac biomarkers beyond cardiovascular health and focuses on their importance in stroke and dementia. The first part describes blood-based cardiac biomarkers in patients with stroke and highlights applications in the setting of early diagnosis, poststroke complications, outcome prediction as well as secondary prevention. Among other applications, natriuretic peptides can be helpful in differentiating stroke subtypes. They are also currently being investigated to guide prolonged ECG monitoring and secondary prevention in patients with stroke. Elevated cardiac troponin after ischemic stroke can provide information about various poststroke complications recently termed the stroke-heart syndrome. The second part focuses on the role of cardiac biomarkers in vascular cognitive impairment and dementia, emphasizing their association with structural brain lesions. These lesions such as silent brain infarcts and white matter hyperintensities often co-occur with cardiac disease and may be important mediators between cardiovascular disease and subsequent cognitive decline. ECG and echocardiogram measurements, in addition to blood-based biomarkers, show consistent associations with vascular brain changes and incident dementia, suggesting a role in indicating risk for cognitive decline. Together, the current evidence suggests that cardiac blood-based, electrophysiological, and imaging biomarkers can be used to better understand the heart and brain connection in the setting of not only stroke but also dementia.