Secondary Prevention Of Cardiovascular Events Research Articles

Overcoming patient reluctance to statin intolerance.

Statin therapy is a cornerstone in the management of dyslipidemia, both in primary and secondary prevention of cardiovascular events. Despite strong guidelines supporting statin use, concerns regarding side effects, particularly musculoskeletal symptoms, contribute to statin intolerance and patient reluctance. While statin intolerance is reported in 5% to 30% of patients, its true prevalence may be overestimated due to the influence of the nocebo effect. Factors associated with higher incidence of statin intolerance include older age, female sex, comorbidities such as diabetes and chronic kidney disease, and concurrent use of medications such as antiarrhythmic agents or calcium channel blockers. Clinical characterization of statin intolerance requires thorough evaluation and exclusion of alternative causes of musculoskeletal symptoms. Strategies to address statin intolerance include reassessing cardiovascular risk, engaging in shared decision-making, statin rechallenge after appropriate washout periods, dosage titration for tolerability, and consideration of alternative therapies when low-density lipoprotein goals cannot be achieved with statins. This review provides an overview of the spectrum of statin intolerance, its clinical assessment, and a systematic approach to caring for a patient with statin intolerance.

Probucol will become a New Model for Treating Cerebral Infarction with a High Risk of Hemorrhage.

Antiplatelet, antihypertensive, and lipid-lowering agents are the three foundational agents for secondary prevention of ischemic stroke, among which lipid-lowering is one of the most important cornerstones. Probucol is a potent antioxidative lipid-lowering drug used to prevent and treat atherosclerotic cardiovascular diseases and xanthomas. However, it has faded from Western markets by lowering LDL-C and HDL-C levels. Probucol alleviates atherosclerosis improving high-density lipoprotein function, and does not increase the risk of cardiovascular events. Probucol-induced pharmacological changes in HDL-C may not be a reliable prognostic marker for cardiovascular risk. Q-T interval prolongation is a rare adverse reaction as described in the manufacturer's instructions, but prolonged Q-T interval may only be an intermediate pharmacological phenomenon of electrophysiological changes, and as a result, probucol has a strong benefit for secondary prevention of cardiovascular events and can reduce mortality without increasing the risk of cardiovascular and cerebrovascular adverse events. The new mechanism is that probucol penetrates the core of lowdensity lipoprotein particles, enhancing the activity of plasma cholesteryl ester transfer protein and liver scavenger receptor type I activity, thereby reducing LDH; at the same time, increasing the activity of paraoxonase 1, strengthened the antioxidant function of HDL, and reduced the serum HDL-C. If clinical or imaging findings suggest a high risk of recurrence of cerebral ischemia with a high risk of cerebral hemorrhage, probucol may be selected for prevention. This article focuses on basic research and clinical evidence and provides new insights into the low bioavailability.

Insights into the current management of dyslipidemia from a clinical pharmacological perspective

The low-density lipoprotein cholesterol (LDL-C) is established as a causative agent of atherosclerotic cardiovascular disease (ASCVD) and lowering plasma LDL-C levels represents the main approach to reduce the risk of cardiovascular events. Statins remain the cornerstone of drug therapy for dyslipidemia. Although moderate- to high- intensity statin therapy has demonstrated consistent benefits for secondary prevention of cardiovascular events, statin monotherapy is insufficient to achieve the guideline-recommended LDL-C levels for high- and very high-risk patients. Some patients cannot tolerate statins, especially when taking long-term high doses. Several non-statin drugs that have a complementary mechanism of action to statins are now available, including ezetimibe, monoclonal antibodies targeted to proprotein convertase subtilisin/kexin type 9 (PCSK9 mAb), and, more recently, inclisiran, bempedoic acid, and evinacumab. Considering the recommendations from guidelines by domestic and international cardiovascular associations, combining these drugs should be contemplated to attain treatment goals for patients. Key words: dyslipidemia, atherosclerotic cardiovascular disease, lipid-lowering drugs, familial hypercholesterolemia, hypertriglyceridaemia, nonstatin therapies.

EE164 Cost-Effectiveness of Inclisiran as Add-on Therapy to Standard-of-Care for the Secondary Prevention of Cardiovascular Events in Patients with Elevated LDL Cholesterol

EE164 Cost-Effectiveness of Inclisiran as Add-on Therapy to Standard-of-Care for the Secondary Prevention of Cardiovascular Events in Patients with Elevated LDL Cholesterol

Mortality and predictors of death in women and men with congestive heart failure due to ischemic and nonischemic cardiomyopathy

Abstract Background Heart failure (HF) is one of the leading causes of death from cardiovascular disease. Studies have shown that women have better survival than men, despite the higher number of hospitalizations among women. However, little is known about differences in mortality and predictors of death in women and men with heart failure due to ischemic (iCMP) and nonischemic (niCMP) cardiomyopathy. Purpose To analyze the mortality and predictors of death in women and men with iCMP and niCMP cardiomyopathy. Methods From February 2017 to September 2020, we analyzed mortality and predictors of death in women and men with CHF by iCMP and niCMP. Baseline data included clinical features and echocardiographic findings. Statistical analyses were performed using the Kaplan-Meier (K-M) method and Cox proportional hazards methods to analyze mortality rates in women and men. We used the Score Chi-Square of Cox regression to search for death predictors for women and men. Results We studied 7,487 patients, mean age of 64.3 ± 14.2 years, 4,417 (59%) males. Women with iCMP and niCMP had, respectively, higher mean age (p<0.0001), higher mean left ventricular ejection fraction (LVEF) (p<0.001), and smaller left ventricular diastolic diameter (LVDD) (p< 0.001). The mean dose of carvedilol was similar in both genders for iCMP and niCMP. Over a 3-year follow-up period, 420 (15.7%) men and 325 (14.7%) women with niCMP died (p=NS), and in iCMP, 519 (29.8%) men and 211 men died. (24.5%) women (p=0.004). Higher mortality was observed in women with iCMP compared to men with iCMP (p<0.0001). The cumulative incidence of death was higher in men (K-M: log-rank p<0.0001) with iCMP, but similar for niCMP (Figure). Cox regression for death adjusted for age, sex, previous myocardial infarction (MI), diabetes, previous stroke, chronic kidney disease (CKD), atrial fibrillation (AF), HF phenotype (systolic, diastolic, or mildly reduced ejection fraction), and LVEF showed that CKD, AF, diabetes, stroke, LVEF, and age, in descending order of Score Chi-Square, were the main predictors of death for niCMP and CKD, stroke, diabetes, AF, LVEF, age, and MI for iCMP. Conclusions Women had a better prognosis than men in iCMP, but similar mortality in niCMP. Gender was not an independent variable of death. Secondary prevention of cardiovascular events from the main predictors of death can significantly reduce the death rate in women and men with CHF by iCMP and niCMP.

Colchicine for the secondary prevention of cardiovascular events

Colchicine for the secondary prevention of cardiovascular events

The Impact of Web-Based Continuing Medical Education Using Patient Simulation on Real-World Treatment Selection in Type 2 Diabetes: Retrospective Case-Control Analysis.

Despite guidelines recommending the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in certain patients with type 2 diabetes (T2D), they are not being prescribed for many of these patients. Web-based continuing medical education (CME) patient simulations have been used to identify clinicians' practice gaps and improve clinical decision-making as measured within a simulation, but the impact of this format on real-world treatment has not been researched. This study aimed to evaluate the effect of a simulation-based CME intervention on real-world use of GLP-1 RAs by endocrinologists and primary care physicians. Two evaluation phases of the CME simulation were conducted: phase I, the CME simulation phase, was a paired, pre-post study of 435 physician learners in the United States; and phase II, the real-world phase, was a retrospective, matched case-control study of 157 of the 435 physicians who had claims data available for the study period. Phase I CME results showed a 29 percentage point increase in correct decisions from pre- to postfeedback (178/435, 40.9% to 304/435, 69.9%; P<.001) in selecting treatment that addresses both glycemic control and cardiovascular event protection. Phase II results showed that 39 of 157 (24.8%) physicians in the intervention group increased use of GLP-1 RAs, compared to 20 of 157 (12.7%) in the comparison group. Being in the intervention group predicted GLP-1 RA use after education (odds ratio 4.49; 95% CI 1.45-13.97; P=.001). A web-based CME simulation focused on secondary prevention of cardiovascular events in a patient with T2D was associated with increased use of evidence-based treatment selection in the real world.

Can previous therapy with statin be considered a protective factor in acute coronary syndrome?

Abstract Funding Acknowledgements Type of funding sources: None. Background Statin therapy is nowadays a cornerstone in primary and secondary prevention of cardiovascular events. Purpose This retrospective observational study intends to characterise the influence of previous therapy with statins on clinical and electrocardiographic presentation of acute coronary syndrome (ACS) and on in-hospital morbidity and mortality. Methods We evaluated a population of 746 patients admitted in a Cardiac Care Intensive Unit diagnosed with ACS (D). We then considered two groups: patients with previous therapy with statins (D1) and patients without it (D2). We documented demographic factors, personal history, clinical and electrocardiographic presentation of ACS, coronary angiography and angioplasty. The following in-hospital complications were defined: heart failure (HF), cardiogenic shock, reinfarction, stroke, major bleeding and need for blood transfusion. In-hospital mortality was compared between both groups. Results D1 consisted of 37.5% of the population (N=280). These patients had a higher prevalence of hypertension (90.7% vs 65.4%, p &amp;lt;0.001), diabetes (45.0% vs 27.8%, p &amp;lt;0.001), dyslipidaemia (81.8% vs. 36.6%, p = 0.001), chronic renal failure (18.6% vs 7.6%, p = 0.001), stroke (10.7% vs. 4.5%, p = 0.003), previous myocardial infraction (MI) (45,0% vs 12,6%, p = 0.001) and previous coronary artery bypass graft (13.2% vs. 2.0%, p = 0.001). They also had more frequently smoking habits (37.4% vs 13.9%, p = 0.001). They were less frequently admitted with ST-elevation MI (24.6% vs 49.2%, p = 0.001) and more frequently with non-ST elevation MI (56.1% vs 40, 9%, p = 0.001) and unstable angina (10.7% vs 5.6%, p = 0.02). The rate of coronary angiography was similar, however patients receiving previous statin therapy underwent less angioplasty. During hospitalization, there were no differences in any of the complications considered, nor in in-hospital mortality between the 2 groups. Conclusions In patients with ACS, previous therapy with statins seems to influence the presentation of ACS but it does not affect in-hospital morbidity and mortality. An important percentage of patients with diabetes and of those with previous MI or stroke were not on statins therapy as recommended in the European guidelines.

Allopurinol

Allopurinol

Aspirin use and bleeding events during thrombocytopenia after autologous stem-cell transplantation for multiple myeloma.

In patients with cardiovascular (CV) comorbidities that necessitate antiplatelet therapy (APT), its optimal management during chemotherapy-induced thrombocytopenia remains elusive, as the risk of bleeding has to be balanced against the risk of CV events. The purpose of this study was to assess the risk for bleeding with APT during thrombocytopenia in patients with multiple myeloma undergoing high-dose chemotherapy and subsequent autologous stem-cell transplantation (ASCT) with and without acetylsalicylic acid (ASA) as comedication. We assessed patients who underwent ASCT at the Heidelberg University Hospital between 2011 and 2020 for bleeding events, management strategies for ASA intake during thrombocytopenia, transfusion requirements, and the occurrence of CV events. There were 57/1,113 patients who continued ASA until at least 1 day after ASCT; thus, a continuous platelet inhibition during thrombocytopenia was assumed. Most of the patients (41/57) continued ASA until they had a platelet count of 20-50/nl. This range reflects the kinetics of thrombocytopenia and nondaily measurements of platelets during ASCT. A tendency toward a higher risk for bleeding events in the ASA group was demonstrated (1.9% (control group) vs. 5.3% (ASA), p = 0.082). The risk factors for bleeding in multivariate analysis were the duration of thrombocytopenia < 50/nl, a history of gastrointestinal bleeding, and diarrhea. The factors predicting the duration of thrombocytopenia were age >60 years, a hematopoietic stem-cell transplantation comorbidity index ≥3, and an impaired bone marrow reserve at admission. CV events occurred in three patients; none of them took ASA or had an indication for APT. The intake of ASA until thrombocytopenia with a platelet count of 20-50/nl appears safe, although an elevated risk cannot be excluded. If ASA is indicated for the secondary prevention of CV events, the evaluation of risk factors for bleeding and a prolonged time of thrombocytopenia before conditioning is crucial to adapt the strategy for ASA intake during thrombocytopenia.

Aspirin vs Clopidogrel: Antiplatelet Agent of Choice for Those With Recent Bleeding or at Risk for Gastrointestinal Bleed.

Antiplatelet agents are used worldwide mainly for primary and secondary prevention of cardiovascular events on a long-term basis for mortality benefit. Gastrointestinal bleeding is a well-known adverse effect. Various factors are to be considered while choosing antiplatelet agents to prevent the risk of bleedand rebleed incidents. These range from deciding on the agent, timing of therapy, underlying indications, coadministration of proton pump inhibitor, etc. At the same time, one must weigh the risks of cardiovascular events secondary to the stoppage of antiplatelet therapy. With this review, we have tried to guide the clinician on decision-making regarding the care of patients on management of acute upper and lower gastrointestinal bleeding, stoppage, restarting of agents, and measures to prevent a recurrence. We have focused on aspirin and clopidogrel as they are among the most widely used antiplatelet agents.

Adherence to Cardiovascular Prevention Guidelines in an Academic Centre

BackgroundAdherence to guidelines is associated with better patient outcomes. Although studies show suboptimal adherence to cardiovascular prevention guidelines among general practitioners, adherence among specialist physicians is understudied. The aim of this analysis was to identify practice gaps among cardiologists in a tertiary academic centre. MethodsWe retrospectively audited cardiology outpatient clinic notes taken at the Cardiology Clinic at the Centre hospitalier de l’Université de Montréal (CHUM), from the period January 1, 2019 to February 28, 2019. Data were abstracted from hospital medical records. The primary outcome of interest was the rate of adherence to cardiovascular prevention guidelines. We compared the chart-documented practice at our centre to the Canadian hypertension, lipid, diabetes, antiplatelet, and heart failure guidelines in effect at the time of the audit. We also collected information regarding discussions of smoking, alcohol consumption, physical activity, and diet. ResultsA total of 2503 patients were included, with a mean age of 65.6 ± 14.5 years. Dyslipidemia occurred in 63% of patients, hypertension in 55%, and coronary artery disease in 41%. Optimal low-density lipoprotein control was documented as having been achieved in just 39% of cases. Blood pressure control was adequate for 65% of patients, and glycemic control was achieved in 47% of patients with diabetes. Heart failure treatment was optimal in 34% of patients. Nearly all patients with coronary artery disease (95%) had appropriate antithrombotic therapy. The incidence of discussion of nonpharmacologic interventions varied, ranging from 91% (smoking) to 16% (diet). ConclusionsPrimary and secondary prevention of cardiovascular events was found to be suboptimal in an academic tertiary-care outpatient cardiology clinic and may be representative of similar shortcomings nationwide. Strategies to ensure guideline adherence are needed.

Utilization of Hypolipidemic Drugs, Patterns, and Factors Affecting Dyslipidemia Among Type 2 Diabetes Mellitus at a Tertiary Care Teaching Hospital in South India.

Background The prevalence of dyslipidemia is higher in type 2 diabetes mellitus (T2DM) and hypolipidemic drugs like statins are effective for the primary and secondary prevention of cardiovascular events. Most of the patients with type 2 diabetes have a mixed type of dyslipidemia. This study aimed to evaluate the utilization of hypolipidemic drugs, patterns, and factors affecting dyslipidemia in T2DM participants. Methods This cross-sectional observational study was approved by the institutional ethics committee (IEC) of the Vydehi Institute of Medical Sciences and Research Center. It was conducted for a period of one year from July 2021 to June 2022. Participants with T2DM visiting the Department of General Medicine and Endocrinology were enrolled after obtaining informed consent. Demographic details, medication history, and laboratory data were recorded in case report form and statistical measures were applied. Results Out of 237 participants enrolled in the study,the predominance (n=133, 56%) was males. The mean age of the study population was 47.92±9.17 years, and the mean duration of diabetes was 6.8±5.3 years. Out of the total participants, 164 (69%) had deranged lipid profiles. Out of them, 129 (78.65%) were on hypolipidemic drugs. Regarding drug utilization, 122 (94.6%) received statins either rosuvastatin (54%) or atorvastatin (40%). In the deranged lipid profilespattern, 24% (58) participants had oneabnormal lipid parameter and the majority 70% (166) had combined lipid profile abnormality. Factors like increased BMI were significantly associated with dyslipidemia(p=0.004). Utilization of hypolipidemic drugs was also significantly associated with the control of dyslipidemia (p<0.001). It was observed that participants who were not on lipid-lowering drugs had 5.38 times more chance ofdyslipidemia (OR=5.38; CI=2.82-10.28; p<0.001). Conclusion A high prevalence of dyslipidemia was observed among diabetic patients. Statins were the most prescribed drug in the study.BMI and lack of pharmacotherapy were found to have a statistically significant association with dyslipidemia in diabetic patients.

Cost-Effectiveness of Vonoprazan Compared With Proton Pump Inhibitors in Patients Taking Low-Dose Aspirin for Secondary Prevention of Cardiovascular Events in Japan.

Low-dose aspirin (LDA) is used to prevent recurrent cardiovascular (CV) events, but is associated with upper gastrointestinal (GI) bleeding; concomitant use of a proton pump inhibitor (PPI) reduces this risk. This study aimed to assess the cost-effectiveness of vonoprazan compared with PPIs (lansoprazole and esomeprazole) in patients taking LDA for secondary prevention of CV events.Methods and Results: A Markov simulation model was developed to predict the number of GI bleeding and acute CV events using 3 strategies (vonoprazan+LDA, esomeprazole+LDA, and lansoprazole+LDA), which were translated into quality-adjusted life-years (QALYs) and costs. Transition probabilities and utilities were derived from the results of published literature, and medical costs were based on the Japanese National Health Insurance fee table and claims databases in 2020. Outcomes were projected over 30 years starting at age 65 years and discounted at 2% annually. Expected costs with esomeprazole 20 mg, lansoprazole 15 mg and vonoprazan 10 mg were JPY 1,225,657, JPY 943,930, and JPY 1,059,510, respectively. The QALY gain for vonoprazan vs. esomeprazole was 0.35, thus vonoprazan was dominant against esomeprazole. The QALY gain for vonoprazan vs. lansoprazole was 0.29 and the incremental cost-effectiveness ratio (ICER) was JPY 398,551, thus, vonoprazan was more cost-effective than lansoprazole. Vonoprazan is dominant or cost-effective compared with esomeprazole and lansoprazole in patients taking LDA for secondary prevention of CV events.

Residual risk in patients with atherosclerotic cardiovascular disease

The residual risk in patients with atherosclerosis, despite the its controversial aspects, remains an urgent problem of modern cardiology. The article presents a review of publications on the prevalence and significance for determining the prognosis of residual risk, which is currently interpreted as the risk of macroand microvascular complications in patients with atherosclerotic cardiovascular disease (ACVD) taking standard therapy, with the achievement of optimal levels of low-density lipoprotein cholesterol, blood pressure and glucose. Based on available publications, we highlighted current views on the factors associated with residual inflammatory and lipid risks in ACVD patients, including those associated with heart failure and diabetes, and the prognostic significance of residual risk in such patients. An attempt was made to rationale the significance of determining the residual risk for secondary prevention of cardiovascular events.

Magnitude of low-density lipoprotein reduction and impact on major cardiovascular outcomes.

Magnitude of low-density lipoprotein reduction and impact on major cardiovascular outcomes.

Real-World Clinical Experience of Rosuvastatin as a Lipid-Lowering Therapy for Primary and Secondary Prevention of Cardiovascular Events (REAL ROSE).

Background Rosuvastatin effectively reduces endogenous cholesterol synthesis and low-density lipoprotein (LDL) cholesterol and increases high-density lipoprotein (HDL) cholesterol. This study aimed to evaluate the clinical characteristics of patients and treatment patterns of rosuvastatin as a lipid-lowering therapy for primary and secondary prevention of cardiovascular events in Indian settings. Methods This real-world, retrospective multi-centric observational study included patients aged >18 years who received treatment with a rosuvastatin/rosuvastatin-based combination. Demographic and data about concomitant diseases and medications were recorded. Results Out of 1,816 patients, the majority were men (66.2%); the mean age was 54.1 years. The patients prescribed rosuvastatin for primary and secondary prevention of cardiovascular events were 71.9% and 28.1%, respectively. Rosuvastatin 10 mg (56.8%) was the most commonly prescribed dose. For primary prevention, 10 mg (65.0%) was the most preferred dose, and for secondary prevention, 20 mg (54.3%) was the most preferred dose. Rosuvastatin treatment significantly (pre- vs. post-treatment) reduced the levels of total cholesterol (227.2 vs. 178.4 mg/dL), triglycerides (212.6 vs. 154.4 mg/dL), and LDL cholesterol (167.0 vs. 125.6 mg/dL), and increased HDL cholesterol levels (40.7 vs. 44.3 mg/dL) (p<0.0001). A total of 1,196 patients received combination therapy with rosuvastatin (aspirin, 34.0%, and fenofibrate, 21.9%). Adverse events were reported in 0.4% of the study population (leg pain, nausea, muscle cramps/pain, bleeding, and myalgia). Conclusion This study demonstrated the clinical effectiveness and safety of moderate- to high-intensity rosuvastatin (5-40 mg) for primary and secondary prevention of cardiovascular events in the Indian population. A primary prevention strategy with statins can reduce cardiovascular events and associated morbidity and mortality.

Optimal target of LDL cholesterol level for statin treatment: challenges to monotonic relationship with cardiovascular events

BackgroundAggressive lipid lowering by high-dose statin treatment has been established for the secondary prevention of coronary artery disease (CAD). Regarding the low-density lipoprotein cholesterol (LDL-C) level, however, the “The lower is the better” concept has been controversial to date. We hypothesized that there is an optimal LDL-C level, i.e., a “threshold” value, below which the incidence of cardiovascular events is no longer reduced. We undertook a subanalysis of the REAL-CAD study to explore whether such an optimal target LDL-C level exists by a novel analysis procedure to verify the existence of a monotonic relationship.MethodsFor a total of 11,105 patients with CAD enrolled in the REAL-CAD study, the LDL-C level at 6 months after randomization and 5-year cardiovascular outcomes were assessed. We set the “threshold” value of the LDL-C level under which the hazards were assumed to be constant, by including an artificial covariate max (0, LDL-C − threshold) in the Cox model. The analysis was repeated with different LDL-C thresholds (every 10 mg/dl from 40 to 100 mg/dl) and the model fit was assessed by log-likelihood.ResultsFor primary outcomes such as the composite of cardiovascular death, non-fatal myocardial infarction, non-fatal ischemic stroke, and unstable angina requiring emergency hospitalization, the model fit assessed by log-likelihood was best when a threshold LDL-C value of 70 mg/dl was assumed. And in the model with a threshold LDL-C ≥ 70 mg/dl, the hazard ratio was 1.07 (95% confidence interval 1.01–1.13) as the LDL-C increased by 10 mg/dl. Therefore, the risk of cardiovascular events decreased monotonically until the LDL-C level was lowered to 70 mg/dl, but when the level was further reduced, the risk was independent of LDL-C.ConclusionsOur analysis model suggests that a “threshold” value of LDL-C might exist for the secondary prevention of cardiovascular events in Japanese patients with CAD, and this threshold might be 70 mg/dl for primary composite outcomes.Trial registrationhttp://www.clinicaltrials.gov. Unique identifier: NCT01042730.

Abstract 14192: Effect of Aspirin Dosing in Patients Treated With P2Y12 Inhibitors for Secondary Prevention of Cardiovascular Events

Background: The ADAPTABLE was a pragmatic randomized controlled trial that found no difference between high dose vs low dose aspirin for secondary prevention of ischemic or bleeding events. Whether concomitant P2Y12 inhibitor therapy modifies the effect of aspirin dose on clinical events remains unclear. Methods: Participants in ADAPTABLE were stratified according to baseline use of clopidogrel or prasugrel (P2Y12 group). Ticagrelor was not permitted due to a black box warning with high dose aspirin. The primary effectiveness endpoint was a composite of myocardial infarction, stroke, or death and the primary safety endpoint was hospitalization for major bleeding. We used multivariable Cox regression to compare the relative effectiveness and safety of aspirin dose within P2Y12 and non-P2Y12 groups. Results: Of the 13,815 (91.6%) participants with available data, 3,051 (22.1%) were on a P2Y12 inhibitor at baseline (clopidogrel: 93.4%; prasugrel: 6.6%). P2Y12 inhibitor use was associated with higher risk of the primary effectiveness endpoint (10.86% vs. 6.31%; adjusted HR 1.44 95% CI 1.22-1.62) but was not associated with bleeding (0.53% vs. 0.95%; adjusted HR:1.42; 95% CI 0.91, 2.22). We found no interaction in the relative effectiveness and safety of high vs. low dose aspirin by P2Y12 inhibitor use (Table, P interaction 0.09 and 0.73 for primary effectiveness and safety endpoint, respectively). Aspirin dose switching and discontinuation occurred in 28.6% of patients. Although this was more common in high dose vs. low dose aspirin, the above rates did not differ between the P2Y12 and non-P2Y12 groups. Conclusion: In this pre-specified subgroup analysis of a large, pragmatic trial, we found that the relative effectiveness and safety of high dose vs. low dose aspirin was not modified by baseline use of P2Y12 inhibitors. Decisions regarding aspirin dosing should be individualized based on clinical factors and patient preference, regardless of P2Y12 inhibitor use.

Sleep Quality Among Patients with Myocardial Infarction

Background: Good sleep is vital for a healthy heart. Studies showed that short sleep duration contributes to the development of myocardial infarction (MI). ST-segment elevated myocardial infarction (STEMI) in comparison to non-ST-segment elevated myocardial infarction (NSTEMI) is considered a dangerous health condition. Sleep qualities among patients with NSTEMI and those with STEMI are less clear in the available literature. So, the author undertook this study. Objective: To assess and compare the sleep quality among patients with STEMI and those with NSTEMI in cardiology units of a tertiary care hospital, Chandigarh. Methodology: The research design was descriptive and the approach used was the quantitative approach. A total of 100 patients were chosen by using the consecutive sampling technique. The interview technique was used to collect data with the help of the interview schedule comprised of socio-demographic profile sheets, clinical profile sheets and the Pittsburgh Sleep Quality Index (to assess the sleep quality). Results: The data revealed that more than 76% of patients were diagnosed with STEMI, whereas less than 24% of patients were diagnosed with NSTEMI. A significantly higher percentage of patients suffering from NSTEMI (40%) reported very good subjective sleep quality than those suffering from STEMI (12%) ( p &lt; 0.05). However, no statistically significant difference was seen in the sleep quality and sleep duration between patients with NSTEMI and those with STEMI as assessed by the Global Sleep Quality Index ( p &gt; 0.05). Conclusion: Each patient, irrespective of their type of MI, reported sleep difficulty. Patients with NSTEMI showed comparatively better sleep quality and sleep duration than those with STEMI. More efforts are required to improve the sleep qualities of patients with both NSTEMI and STEMI for the prevention of secondary cardiovascular events.