Zahid, Salman

Background Optimal duration and choice of antiplatelet therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention remain controversial. Methods and Results Digital databases (PubMed, Cochrane, and Embase) were queried to select all randomized controlled trials on a post–percutaneous coronary intervention population with acute coronary syndrome. Dual‐antiplatelet therapy (DAPT) with aspirin and clopidogrel for 12 months was compared with 4 major strategies: high‐potency, high‐ to low‐potency, low‐dose, and short‐duration DAPT. A network meta‐analysis was performed to compare the safety and efficacy of different antiplatelet strategies. This study was the second updated manuscript under the International Prospective Register of Systematic Review registration (CRD42021286552). Thirty‐two randomized controlled trials comprising 103 459 (51 750 experimental, 51 709 control) patients were included. Compared with DAPT with aspirin and clopidogrel for 12 months, high‐ to low‐potency DAPT (risk ratio [RR], 0.69 [95% CI, 0.52–0.92]) and aspirin+prasugrel containing DAPT for 12 months (RR, 0.84 [95% CI, 0.72–0.98]) had a significantly lower, whereas DAPT for 1 month followed by clopidogrel only (RR, 1.59 [95% CI, 1.06–2.39]) had a higher, incidence of major adverse cardiovascular events at 1 year (median follow‐up). Prasugrel (RR, 1.35 [95% CI, 1.09–1.66]) and ticagrelor (RR, 1.38 [95% CI, 1.17–1.62]) containing DAPT for 12 months had significantly higher rates, whereas high‐ to low‐potency DAPT (RR, 0.85 [95% CI, 0.63–1.15]) had no significant risk of major bleeding. Conclusions Aspirin and ticagrelor for 3 months, followed by aspirin and clopidogrel for the remaining duration, can be considered the optimal strategy for treating post–percutaneous coronary intervention patients with acute coronary syndrome because of a significantly reduced risk of major adverse cardiovascular events without increasing the risk of bleeding.

Background: Cardiac amyloidosis (CA) in conjunction with atrial fibrillation (AF) presents unique management challenges. CHA2DS2VASc score in these patients is believed to underestimate the risk of ischemic stroke, necessitating a better predictive model in these patients. Methods: Data was obtained from the National Readmission Database (NRD). Outcomes between CA-AF and no-CA-AF were compared using multivariate regression analysis to calculate adjusted odds ratios (aOR). AutoScore; an interpretable machine learning framework, was used to develop a stroke risk prediction model, the predictive accuracy of which was evaluated with an area under the curve (AUC) using the receiver operating characteristic analysis. Results: A total of 11,860,804 (CA-AF 22,687 [0.19%] and no-CA-AF 11,838,117) patients were identified from 2015-2019. The adjusted odds of mortality (aOR 1.41 and 1.29), stroke (aOR 1.78 and 1.74), non-intracranial hemorrhage (aOR 2.10 and aOR 1.85), and intracranial hemorrhage (aOR 14.4 and aOR 4.26) were significantly higher in CA-AF compared with non-CA-AF at both index admission and 30-days, respectively. The CHA 2 DS 2 VASc score had a poor discriminative accuracy for stroke at 30-days in CA-AF (AUC 49%, 95%CI 47%-51%, p=0.54). The machine learning autoscore integrative model revealed that the predictive ability of our newly proposed E-CHADS score (end-stage renal disease (ESRD), congestive heart failure, hypertension, active cancer, dementia, and diabetes mellitus) for 30-day risk of ischemic stroke in CA-AF was excellent (for a cutoff of 52 points random forest score) with an AUC of 80% (95%CI 74%-86%) Conclusion: Cardiac amyloidosis carries a high risk of ischemic stroke that is not accurately predicted by the CHA 2 DS 2 VASc score. Our proposed model (E-CHADS) identifies 3 new variables (ESRD, dementia, and cancer) that have higher discriminative accuracy for ischemic stroke in these patients.

Introduction: Persons who conceived through Assisted Reproductive Technology (ART) have an increased risk of obstetric-associated complications. Hypothesis: ART is associated with increased acute cardiovascular (CV) complications during delivery admissions. Methods: We used data from the National Inpatient Sample (2008-2019) while utilizing ICD-9 or ICD-10 codes to identify delivery hospitalizations and ART procedure. Results: A total of 45,867,086 weighted delivery cases were identified, of which 0.24% were among individuals who conceived through ART (n=108,542). Persons with an ART history were older at the time of delivery (median 35 vs. 28 years, p<0.01) and had higher prevalence of hypertension, gestational diabetes, and dyslipidemia (all, p<0.01). After adjustment for age, race/ethnicity, comorbidities, multiple gestation, insurance, and income, ART remained an independent predictor of peripartum CV complications including preeclampsia (aOR 1.48 [1.45-1.51], p<0.01), heart failure (aOR 1.94 [1.10-3.40], p<0.01), and cardiac arrhythmias (aOR 1.39 [1.30-1.48], p<0.01) compared to natural conception. Likewise, the risk of acute kidney injury (aOR 2.57 [2.25-2.92], p<0.01), stroke (aOR 1.57 [1.23-2.01], p<0.01), pulmonary edema (aOR 2.29 [2.02-2.61], p<0.01), and venous thromboembolism (aOR 1.92 [1.63-2.25], p<0.01) were higher with ART. However, higher odds of developing peripartum cardiomyopathy or acute coronary syndrome were not associated with ART. Length of stay (3 vs. 2 days, p<0.01) and cost of hospitalization ($5,903 vs. $3,922, p<0.01) were higher for deliveries among persons with history of ART. Conclusions: Persons who conceived with ART had higher risk of preeclampsia, heart failure, cardiac arrhythmias, pulmonary edema, AKI, stroke, and VTE during their delivery hospitalizations. This may in part contribute to increased resource utilization seen in patients conceiving with ART

Purpose: Studies on outcomes related to endovascular treatment (EVT) in advanced stages of chronic kidney disease (CKD) and end-stage renal disease (ESRD) among hospitalizations with acute limb ischemia (ALI) are limited. Methods: The Nationwide Inpatient Sample was quarried from October 2015 to December 2017 to identify the hospitalizations with ALI and undergoing EVT. The study population was subdivided into 3 groups based on their CKD stages: group 1 (No CKD, stage I, stage II), group 2 (CKD stage III, stage IV), and group 3 (CKD stage V and ESRD). The primary outcome was all-cause in-hospital mortality. Results: A total of 51 995 hospitalizations with ALI undergoing EVT were identified. The in-hospital mortality was significantly higher in group 2 (OR = 1.17; 95% CI 1.04 – 1.32, p=0.009) and group 3 (OR = 3.18; 95% CI 2.74–3.69, p<0.0001) compared with group 1. Odds of minor amputation, vascular complication, atherectomy, and blood transfusion were higher among groups 2 and 3 compared with group 1. Group 2 had higher odds of access site hemorrhage compared with groups 1 and 3, whereas group 3 had higher odds of major amputation, postprocedural infection, and postoperative hemorrhage compared with groups 1 and 2. Besides, groups 2 and 3 had lower odds of discharge to home compared with group 1. Finally, the length of hospital stay and cost of care was significantly higher with the advancing CKD stages. Conclusion: Advanced CKD stages and ESRD are associated with higher mortality, worse in-hospital outcomes and higher resource utilization among ALI hospitalizations undergoing EVT. Clinical Impact Current guidelines are not clear for the optimum first line treatment of acute limb ischemia, especially in patients with advanced kidney disease as compared to normal/mild kidney disease patients. We found that advanced kidney disease is a significant risk factor for worse in-hospital morbidity and mortality. Furthermore, patients with acute limb ischemia and advanced kidney disease is associated with significantly higher resource utilization as compared to patients with normal/mild kidney disease. This study suggests shared decision making between treating physician and patients when considering endovascular therapy for the treatment of acute limb ischemia in patients with advanced kidney disease.