Faculty Bibliography

Background: The recent AHA/ACC guidelines on duration of dual anti-platelet therapy (DAPT) recommends DAPT for 1 year in patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI), with a Class IIb recommendation for continuation. Methods: We searched electronic databases to identify randomized trials comparing short-term (<=6 months) vs 12 months vs extended (>12 months) DAPT in patients with ACS undergoing PCI. We evaluated allcause and cardiovascular mortality, myocardial infarction (MI), stent thrombosis and major bleeding. Random effects modeling was used to calculate pooled relative risk (RR) and 95% confidence intervals (CI). Results: We included 8 trials comprising of 12,917 ACS patients; 5 trials compared short-term vs 12 months or extended DAPT, whereas 3 trials compared 12 months vs extended DAPT. There were no significant differences in either ischemic or bleeding outcomes between short-term vs 12 months or extended DAPT. However compared to extended DAPT, 12 months DAPT showed significantly higher risk of MI (RR 2.00, 95% CI: 1.47 to 2.73, p<0.001) but reduced risk of major bleeding (RR 0.58, 95% CI: 0.34 to 0.98, p=0.04). All-cause mortality was similar between 12 months vs extended DAPT. The heterogeneity was low to moderate (I2 ranged from 17% to 39%). Conclusion: In ACS, DAPT beyond 1 year should be based on an individualized patient approach taking into account the competing risks of bleeding and ischemic complications. (Table Presented)

Background: Acute myocardial infarction (AMI) is a significant cardiovascular complication following non-cardiac surgery. We evaluated national trends in perioperative AMI, management, and outcomes using a large administrative database of United States hospital admissions. Methods: Patients who underwent non-cardiac surgery from 2005 to 2013 were identified using the National Inpatient Sample. Perioperative AMI was evaluated over time. Propensity score matching was used to compile cohorts of patients with perioperative AMI matched on their baseline characteristics who were managed invasively (defined as cardiac catheterization, percutaneous coronary intervention [PCI], or coronary artery bypass graft surgery [CABG]) versus conservatively. The primary outcome was in-hospital all-cause mortality. Results: Among 9,566,277 hospitalizations for major non-cardiac surgery, perioperative AMI occurred in 84,093 (0.88%). Over time, the rate of perioperative AMI per 100,000 surgeries declined by 170 (95% CI 158 - 181), from 898 in 2005 to 729 in 2013 (p for trend <0.0001). Perioperative AMI occurred most frequently in patients undergoing vascular (2.0%), transplant (1.6%), and thoracic (1.5%) surgery. In-hospital mortality was higher in patients with perioperative AMI than those without AMI (18.0% vs. 1.5%, p<0.0001; adjusted OR 5.76, 95% CI 5.65 - 5.88). Mortality associated with perioperative AMI declined over time (adjusted OR 0.86, 95% CI 0.84 - 0.88). In a propensity-matched cohort of 34,650 patients with perioperative AMI, invasive management was associated with lower mortality than conservative management (8.9% vs. 18.1%, p<0.001; OR 0.44, 95% CI 0.41-0.47). Conclusion: Perioperative AMI occurs in 0.9% of patients undergoing major non-cardiac surgery and is strongly associated with in-hospital mortality. Invasive management of such patients may mitigate some of this excess risk

Von Willebrand disease (VWD) is an inherited bleeding disorder that often manifests clinically with hemorrhage after invasive procedures. We investigated the association between a diagnosis of VWD and bleeding and thrombotic outcomes following major non-cardiac surgery in a large national database from the United States. Patients age >/=45 years requiring major non-cardiac surgery were identified from Healthcare Cost and Utilization Project's National Inpatient Sample data. Von Willebrand disease, perioperative major adverse cardiovascular events (MACE), thrombotic events, and hemorrhage were defined by ICD9 diagnosis codes. From 2004 to 2013, a total of 10,581,621 hospitalizations for major non-cardiac surgery met study inclusion criteria and VWD was identified in 3765 (0.036%). In adjusted analyses, patients with VWD were significantly more likely to develop post-operative hemorrhage than patients without VWD (5.5 vs. 1.9%, p < 0.001; adjusted OR 3.49, 95% CI 3.03-4.03), but had similar odds of perioperative MACE and thrombotic events. Thus, a diagnosis of VWD was associated with increased risks of bleeding with non-cardiac surgery, without a corresponding reduction in perioperative thrombosis in comparison to patients without VWD. Perioperative management of patients with hereditary bleeding disorders and mitigation of thrombotic risks requires further study.

Background Body-weight fluctuation is a risk factor for death and coronary events in patients without cardiovascular disease. It is not known whether variability in body weight affects outcomes in patients with coronary artery disease. Methods We determined intraindividual fluctuations in body weight from baseline weight and follow-up visits and performed a post hoc analysis of the Treating to New Targets trial, which involved assessment of the efficacy and safety of lowering low-density lipoprotein cholesterol levels with atorvastatin. The primary outcome was any coronary event (a composite of death from coronary heart disease, nonfatal myocardial infarction, resuscitated cardiac arrest, revascularization, or angina). Secondary outcomes were any cardiovascular event (a composite of any coronary event, a cerebrovascular event, peripheral vascular disease, or heart failure), death, myocardial infarction, or stroke. Results Among 9509 participants, after adjustment for risk factors, baseline lipid levels, mean body weight, and weight change, each increase of 1 SD in body-weight variability (measured according to average successive variability and used as a time-dependent covariate) was associated with an increase in the risk of any coronary event (2091 events; hazard ratio, 1.04; 95% confidence interval [CI], 1.01 to 1.07; P=0.01), any cardiovascular event (2727 events; hazard ratio, 1.04; 95% CI, 1.02 to 1.07; P<0.001), and death (487 events; hazard ratio,1.09; 95% CI, 1.07 to 1.12; P<0.001). Among patients in the quintile with the highest variation in body weight, the risk of a coronary event was 64% higher, the risk of a cardiovascular event 85% higher, death 124% higher, myocardial infarction 117% higher, and stroke 136% higher than it was among those in the quintile with the lowest variation in body weight in adjusted models. Conclusions Among participants with coronary artery disease, fluctuation in body weight was associated with higher mortality and a higher rate of cardiovascular events independent of traditional cardiovascular risk factors. (Funded by Pfizer; ClinicalTrials.gov number, NCT00327691 .).

PURPOSE OF REVIEW: Approximately one-fourth of the adult population is diagnosed with hypertension, which has been associated with increased cardiovascular morbidity and mortality including cardiovascular death, myocardial infarction, heart failure and stroke. Early detection and treatment is a key and can lead to a significant reduction in cardiovascular morbidity and mortality. RECENT FINDINGS: In this review, we discuss the management and treatment strategies in patients with hypertension in the current era. Blood pressure (BP) targets will be reviewed in accordance with the recent literature and current guidelines. There is a controversy about lower BP target in patients with coronary artery disease with some studies showing a J-curve relationship but a recent randomized trial (SPRINT) showing a benefit, albeit with controversy as to how BP was measured in the trial. Nevertheless, lower BP targets come with a price of needing more medication (thus impacting cost and compliance) and increases in medication-related adverse effects. There is a growing recognition that angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, calcium antagonists or thiazide diuretics can be used a first-line therapy for hypertension. Evidence also supports the use of combination drug therapy as opposed to monotherapy for more synergistic effect on lowering of BP, offsetting side effects and for improved adherence to a drug regimen. SUMMARY: Overall, we aim to review BP targets and medical therapies for hypertension in the current era, recognizing varying clinical characteristics such as comorbidities and patient-risk profile.