Olson, April

Introduction: Stroke-related mortality poses significant challenges in the US. Increased at-home deaths since COVID-19 pandemic prompted changes in the provision of end-of-life care. Question: What were the settings of stroke deaths in the US during COVID-19 pandemic? Methods: Decedent-level mortality data from death certificates in CDC repository were obtained for the year 2020 (pandemic) and 2019 (comparison). Demographic data include age, sex, race/ethnicity, education, marital status, and place of stroke death, including inpatient, outpatient/emergency room (ER), hospice/nursing facilities (H/NF), and at-home. Multivariable logistic regression models assessed demographic impact on stroke mortality by place-of-death, yielding odds ratios (OR) with significance threshold of p<0.05. Results: A total of 5,400 and 5,712 stroke-related deaths occurred in 2019 and 2020, respectively. During COVID-19, decedents >65 years were more likely to die in H/NF (OR 10.05, p<0.001) but less likely in outpatient/ER (OR 0.32, p<0.001) or at home (OR 0.57, p=0.007) compared to those <35 years. High education level did not significantly influence the place of death than having high school diploma or less (p>0.05). Males were more likely to die at home (OR 1.38, p<0.001) but less likely as inpatient (OR 0.79, p<0.001) than females. Hispanic decedents had a higher likelihood of inpatient death (OR 1.22, p=0.041) but less likely to die in H/NF (OR 0.55, p<0.001) compared to non-Hispanic decedents. Compared to White decedents, Black decedents were more likely to die in outpatient/ER (OR 1.44, p=0.018), while American Indian decedents were more likely to die as inpatient (OR 3.12, p=0.005). Asian/Pacific Islander decedents had a higher chance of inpatient death (OR 1.47, p=0.002) but a lower likelihood of dying in H/NF (OR 0.61, p=0.010). Married decedents were more likely than singles to die as inpatient (OR 1.37, p=0.001) or in outpatient/ER (OR 1.99, p<0.001), but less likely to die in H/NF (OR 0.61, p=0.002) or at home (OR 0.56, p<0.001). Conclusion: Our analysis revealed the influence of demographics on the settings of stroke fatalities during the COVID-19 pandemic. Further investigation is needed to determine contributing factors.

Background Hyperlipidemia is a major cardiovascular disease (CVD) risk factor, but there are limited data on its mortality trends in CVD over time. We assessed annual hyperlipidemia‐related CVD mortality trends in the United States, including the COVID‐19 pandemic's impact. Methods and Results Mortality data were obtained from the Centers for Disease Control and Prevention repository between 1999 and 2020 among patients ≥15 years old, using International Classification of Diseases, Tenth Revision ( ICD‐10 ) codes for hyperlipidemia (E78.0–E78.5) and CVD (I00–I99). Age‐adjusted mortality rates (AAMRs) per 1 000 000 population were standardized to the 2000 US population. Log‐linear regression models were used to evaluate mortality shifts. Average annual percentage change from 1999 to 2019 was used to project 2020 AAMRs, estimating pandemic‐attributed excess deaths. From 1999 to 2020, 483 155 hyperlipidemia‐related CVD deaths occurred. Despite a general CVD mortality decline, hyperlipidemia‐related CVD AAMRs rose from 36.33 in 1999 to 99.77 in 2019. Ischemic heart diseases (AAMR 49.39) were the leading cause, whereas hypertension had the highest mortality increase (average annual percentage change +10.23%). Mortality rates were higher in men (AAMR 104.87) and non‐Hispanic (AAMR 82.49), and rural populations (AAMR 89.98). Highest mortality was observed in Black populations (AAMR 84.35), those ≥75 years old (AAMR 646.45), and Western US regions (AAMR 96.88). During the first pandemic year, deaths exceeded projections by 10.55%, with notable increases among ages 35 to 75 (14.23%), Hispanic (17.96%), Black (14.82%), and urban (11.68%) groups. Conclusions Hyperlipidemia‐related CVD mortality has risen over the past 2 decades, further heightened by the COVID‐19 pandemic, with higher impact on men, Black Americans, the older population, and rural residents. Further study is needed to understand contributing factors and mitigate disparities.

Antithrombotic treatment in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) poses a dilemma. We compared outcomes of dual antithrombotic therapy (DAT) (direct oral anticoagulants (DOACs)/warfarin + antiplatelets) vs triple antithrombotic therapy (TAT) (DOACs/warfarin, aspirin, and P2Y12 inhibitor) in this population. Multiple databases were searched from inception to December 17, 2023 to identify randomized controlled trials (RCTs) comparing DAT vs TAT in patients with AF and ACS. Outcomes included major adverse cardiac events (MACE), bleeding events, stroke, stent thrombosis, and myocardial infarction (MI). Relative risk and 95% confidence intervals were estimated with a random-effects model using the inverse-variance technique. We assigned I 2 > 50% as an indicator of statistical heterogeneity. p -Value <0.05 was considered significant. Ten RCTs comprising 6186 patients on TAT (female 26%, mean age 71 ± 9 years) and 6800 patients on DAT (female 27%, mean age 71 ± 9 years) were included. Patients receiving DAT experienced lower rates of bleeding events compared to those receiving TAT, with relative risks of 0.69 [0.55–0.87] ( p < 0.001), 0.65 [0.40–1.06] ( p = 0.09), and 0.62 [0.46–0.84] ( p < 0.001) for TAT durations of 3, 6, and 12 months, respectively. No difference was seen in the occurrence of MACE, MI, stroke, or stent thrombosis between DAT and TAT across all three durations of TAT. This is the largest pooled analysis comparing TAT to DAT stratified by the duration of antithrombotic therapy. Our results revealed that DAT was associated with reduced bleeding risk despite no difference in other outcomes.