Podcasts about dapt

This episode reviews new evidence supporting extended DAPT beyond one year for selected patients after multivessel PCI, the role of MRD-guided decisions for maintenance lenalidomide in multiple myeloma, adjuvant ensartinib for resected ALK-positive NSCLC, and emerging data on semaglutide and combination therapy for MASH-related cirrhosis. The studies highlight how precision medicine continues to refine treatment duration, biomarker-driven care, and therapeutic selection across multiple specialties.

Neste Pocket Pill, discutimos quais pacientes podem se beneficiar do prolongamento da DAPT (Dual Antiplatelet Therapy) após uma síndrome coronariana aguda ou intervenção coronária percutânea. A decisão exige equilíbrio entre a redução do risco isquêmico e o aumento do risco de sangramento, tornando a individualização fundamental.

DAPT back in the news, a practice-changing trial in VTE therapy, new knowledge in sudden cardiac death, heart failure definitions updated, and a dumb decision by NICE in the UK are the topics discussed by John Mandrola, MD, in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I Antiplatelet Therapy After Stenting DAPT-MVD Trial https://www.nejm.org/doi/full/10.1056/NEJMoa2517588 HOST-EXAM Trial at 2 years https://pubmed.ncbi.nlm.nih.gov/34010616/ HOST-EXAM Trial at 10 years 10.1016/S0140-6736(26)00422-8 External Link Nick Kurzen on X https://x.com/ncurzen/status/2077676739463922151 II Aspirin Proves Its Mettle After Hip and Knee Replacement EPCAT III Trial https://www.nejm.org/doi/full/10.1056/NEJMoa2603649 CRISTAL Trial https://jamanetwork.com/journals/jama/fullarticle/2795528 III New (and old) Knowledge in Sudden Cardiac Death Sudden Cardiac Death and its Relation to Cardiac Disease at Autopsy https://doi.org/10.1016/j.jacc.2026.01.029 Sudden Cardiac Death Due to MI With Obstructive and Nonobstructive Coronary Arteries https://doi.org/10.1016/j.jacc.2026.01.030 Frequency of Sudden Cardiac Death and Profiles of Risk https://www.ajconline.org/article/S0002-9149(97)00477-3/fulltext IV Heart Failure Diagnosis AHA/ACC/ESC/WHF Expert Consensus Document http://jacc.org/doi/10.1016/j.jacc.2026.05.036 V NICE Makes a Dumb Decision NICE Recommends New Nonsteroidal MRA for Heart Failure https://www.medscape.com/viewarticle/nice-recommends-new-nonsteroidal-mra-heart-failure-2026a1000nzv You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Intracerebral hemorrhage carries high morbidity and mortality, but growing evidence highlights meaningful opportunities for prevention, risk reduction, and long-term recovery. This episode covers key strategies, including blood pressure management, interpretation of neuroimaging markers, and individualized decisions around antithrombotic therapy. It also emphasizes the prolonged recovery timeline and the importance of a holistic, patient-centered approach to improving outcomes. In this episode, Casey S. Albin, MD, FAAN, speaks with Wendy C. Ziai, MD, and Vishank A. Shah, MD, coauthors of the article "Intracerebral Hemorrhage" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Ziai is a professor of neurology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland. Dr. Shah is an assistant professor of neurology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland. Additional Resources Read the article: Intracerebral Hemorrhage Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @caseyalbin Guest: @VishankShah3 Full episode transcript available here Dr Albin: A patient has suffered an intracerebral hemorrhage. They're taken to the neuro ICU, and they fortunately survive. But the journey does not end there. In fact, in some ways, the journey has just begun. Join us today as we unpack holistic care for ICH patients.  Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast.  Dr Albin: Hello to our audience. This is Dr. Casey Albin. Today, I'm interviewing Dr. Wendy Ziai and Dr. Vishank Shah about their article on intracerebral hemorrhage. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast. I am so delighted that both of you are joining. To begin, let's just do a brief introduction of who you are and, and a little bit of how you got interested in the topic.  Dr Ziai: Hi, I'm Wendy Ziai. Thank you for having me on this podcast. I am a professor of neurology at Johns Hopkins. I am a neurointensivist, and I think I got primarily interested in this topic through clinical trials that I have been a part of since my fellowship days.  Dr Shah: Hi, everyone. I'm, uh, Vishank Shah. I am also, uh, very thankful for being invited to be a part of this podcast. I'm also a neurointensivist at Hopkins and the fellowship program director here for neurocritical care, and I'm interested in recovery after ICH, and that's why I'm a part of this work.  Dr Albin: Welcome to you both. It is such a treat for me to get to interview fellow neurointensivist, particularly those who have such a wealth of experience. So, I am delighted to dive into this. All right. So, to set the stage for our audience, intracerebral hemorrhage has long been approached with pessimism. But your article really highlights that there are meaningful advantages in prevention and risk stratification and long-term recovery for these patients. Though you both are neurointensivist, this article really emphasizes primary prevention and the holistic long-term care for the survivors. And so, to begin, Dr. Shah, can you just lay out a little bit for our listeners the scope of intracerebral hemorrhage and its community impact?  Dr Shah: Yeah. So, you know, ICH is the second most common type of stroke. There are more than three million new cases of ICH globally each year, and it accounts for thirty percent of all stroke types, but it is the one that has the highest mortality, with more than forty to fifty percent of the patients dying in the first thirty days, and then continued long-term impact on both functional as well as outcomes, as well as survivorship after the early period. And it also disproportionately impacts lower socioeconomic, and then minority races like Blacks, Asians, as well as Hispanic ethnicity. And so, there's a lot of work that needs to be done to reduce the burden of this disease.  Dr Albin: Absolutely. I mean, these can really be devastating for families, and I really am appreciative of your highlighting that there's a lot of disparities, and there's a lot of work to be done to really increase equity to these patients. I think a lot of this goes into really the AAN's focus on brain health and trying to improve some of what we're doing to maintain brain health. And I really wanted to kind of drill down on this because for ICH, there's a lot that can be done upfront as we think about how do we counsel patients who may walk into the office about strategies to prevent ever becoming an intracerebral hemorrhage patient. So, Dr. Shah, can you walk us through a little bit about what neurologists in the community need to be doing to make sure that no one ends up with us in the neurointensive care unit?  Dr Shah: Yeah, sure. So, I think, you know, one of the most important risk factors is, of course, hypertension and long-standing uncontrolled hypertension. And so really recognizing the need for early onset screening with regular blood pressure monitoring at a very early age, particularly in the races that I discussed earlier. And then I think another big part, obesity, metabolic syndrome, and type two diabetes. And I think there's a lot of interesting new work that with the GLP-1 agonist, you know, in a large multicenter cohort studies showing that patients receiving these had a significantly lower reduction risk of ICH. And so, this might be a really important part that, you know, clinicians need to start increasingly recognizing and using in their practice. And then, of course, other risk factors that are common include smoking, diet high in sodium, exposure to air pollution, both indoor as well as outdoor. And so, mitigating all of these risk factors can also reduce the burden of ICH.  Dr Albin: Absolutely. And I really want to highlight that hypertension plays such an important role and that we as neurointensivist, as community neurologists, really need to be creative about ways that we can help people meet those blood pressure target and meeting people in the community where they are, making sure that they're not suffering from side effects from their medication that would prevent them from sticking with it long term. Dr. Ziai, anything else to add about what we can do in the community?  Dr Ziai: So, we really want to emphasize, even in the acute phase, that patients moving forward need to have targeted interventions to reduce blood pressure, smoking, enhance their physical activity, have a diet that is high in fruits and vegetables and low in alcohol and salt, and then promoting weight loss, of course.  Dr Albin: And Dr. Ziai, I'm gonna ask you a little bit about one of the things that maybe not all of our listeners have heard about is this APOE2, APOE4 genetic risk for intracerebral hemorrhage. What's going on there and, and should clinicians be testing for that? Dr Ziai: That's a great question, and it is not one that we currently test people for at least acute ICH presentation. APOE2 and A4- E4 alleles, these give patients a two to three times higher risk of ICH by increasing cerebral amyloid deposition. And if you happen to have APOE2 carrier ship status, then along with other risk factors like white matter disease and vascular risk factors, these predict the onset of new microbleeds even during very short follow-up periods of about two years. And as we know, having cerebral microbleeds are associated with an increased risk of all strokes, ischemic and ICH, but they are one of many MRI markers of small vessel disease, which along with cortical superficial siderosis, does significantly increase future ICH risk. And so even in people who've never had an ICH, if they happen to have an MRI, it may be reasonable to look at the MRI and incorporate this burden of small vessel disease, and especially these hemorrhagic markers into, uh, decision-making about interventions.  Dr Albin: That's a really excellent point. And so, I think that your article did a really beautiful job of thinking holistically about the patient, incorporating clinical markers of their risk for having ICH, but also those radiographic markers. I'm just gonna ask you to summarize those again one more time because not everyone will be familiar with these. So, when you're looking at an MRI, what are the things that you're particularly clued in on that would increase the patient's risk of future ICH?  Dr Ziai: In the past, what we're looking for really is markers of cerebral amyloid angiopathy, which significantly increase a person's risk for lobar hemorrhage in particular. And so, we have a set of criteria called the Boston Criteria, and there's a new version of these, version 2.0. And these, um, incorporate a number of imaging markers that provide a very high sensitivity and specificity to diagnose CAA after an ICH. But even if someone's never had an ICH, and they evaluate that risk-benefit ratio for different cardiovascular prevention strategies. And so, the markers that we're specifically interested in are, of course, microbleeds. But not just having microbleeds, but are they lobar or are they deep? Lobar having a higher risk for lobar ICH. How many microbleeds are there? Is it greater than five, or is it just one or two? Also, cortical superficial siderosis is a marker, a hemorrhagic marker, that does portend a significant increased risk of recurrent ICH, along with having a lobar ICH. And now we have these new markers, which are the white matter hyperintensity multi spot pattern, which requires these hyperintensities on flare imaging in the subcortical area, having greater than at least ten of these multi spots, and also having enlarged perivascular spaces in the centrum semiovale, and having at least twenty of those. And finally, white matter hyperintensities, which can be measured with the physica score or just by visualizing them. We can look at white matter hyperintensities as well as being a measure of small vessel disease.  Dr Albin: Got it. And so just to summarize, we're looking for small vessel disease markers because that puts our patients at higher risk of ongoing future bleeds. And then we're also looking for markers of particularly small vessel disease that's caused by cerebral amyloid angiopathy, which again, because it's having that protein deposition, that puts the patient at risk of those leptomeningeal very small vessels, putting the patient at risk of lobar ICH. Just confirming I've summarized this all correctly.  Dr Ziai: Yes. That was perfect.  Dr Albin: Amazing. Dr. Shah, I'm gonna go back to you. Let's say we have a patient. Let's say this is a sixty-five-year-old man who comes in and they want follow-up and they're... And you're trying to think about they've had an ICH in the past, and they are also at risk for ischemic disease. Let's say they, they have hypertension, they've had a smoking history. They have some risk for ischemic events. And you're trying to think about how do you balance those. Let's say the patient needs to be on aspirin but does have some of those high-risk features on their MRI. Is there any guidance on how we think through preventing them from having a recurrent bleed if they're a high-risk patient, also preventing them from having an ischemic event, which they might be at high risk for as well?  Dr Shah: Yes. So, I think, you know, the first step is of course trying to understand what was the type of bleed. I think that has a very important role, like you mentioned. If it's a lobar hemorrhage versus a deep hemorrhage, the risk of recurrent ICH and ischemic events is very variable. So lobar hemorrhages, there's obviously a higher risk of recurrent hemorrhage events, whereas deep hemorrhage is actually at or behaves sort of like small vessel ischemic strokes and have a higher risk of recurrent arterial ischemic events. So that distinction in itself can help you gauge which patients would be safe and would benefit from these therapies. To begin, and of course, looking for some of these markers on MRI that were mentioned by Dr. Ziai for recurrence of hemorrhage risk. In terms of antiplatelet, the, there is a lot more data now to guide treatment, and we have the RESTART as well as the ESTART trial that showed that starting an, a single antiplatelet after intracerebral hemorrhage did not increase the risk of hemorrhage recurrence. They were very variable in the timing when aspirin was started, and so that remains still a question about what is the safest time point to start aspirin. For example, in the ESTART trial, they started them very early, within the first three days, whereas in  the RESTART it was all the way up to two months after the hemorrhage. And so... But in general, the risk of recurrent ICH was very low with a single antiplatelet agent. And so, if it's needed for ischemic prevention, it's relatively safe broadly across all types of hemorrhages.  Dr Ziai: Yeah. I would just mention that there was also a subgroup analysis of the RESTART trial using MRI. And so, this more than likely included patients with CAA, since 40% of the hemorrhages were lobar in that study, and therefore seeing that there was no increased risk of recurrent ICH in RESTART, it is thought that putting patients back on their antiplatelet therapy is safe.  Dr Albin: That's a really huge takeaway pearl for our listeners, that regardless of whether it's a lobar bleed or a deep bleed, if there is a strong indication, you know, this is not just, oh, because someone gave them aspirin 81, but truly that there is a reason that they need to be on a single antiplatelet agent, it probably benefits them to be on that agent, and there's good data that there's not a huge increase in risk. Summarizing all of that?  Dr Ziai: Great.  Dr Albin: Now, things are gonna get a little bit tricky here, because what if the patient, what if they need to be on dual antiplatelet therapy? Or what if they need to be on anticoagulation? Dr. Ziai, I'll, I'll throw that to you. How do you tackle that patient population?  Dr Ziai: Yeah, the safety of dual antiplatelet therapy hasn't really been studied in patients who've had a prior ICH. Although, in people who've had previous strokes, putting them on dual antiplatelets doesn't seem to increase the risk of ICH, but it does increase extracranial hemorrhage. And so there may be other reasons not to put patients on dual antiplatelet agents. Patients who have cancer and also cardiovascular or cerebrovascular disease, putting them on dual antiplatelet therapy does seem to increase the risk for intracranial hemorrhage. So, I think there is enough of a bias against DAPT therapy in patients who have had an ICH that we would not recommend DAPT for patients with a prior ICH.  Dr Albin: Absolutely. And, and then what about, let's say they have atrial fibrillation, and you know that they have a high CHA2DS2-VASc score, and they are at very high risk of ischemic events, but they've also had a prior intracerebral hemorrhage. Walk us through a little bit, how should we approach that patient? Dr. Ziai, I'm gonna start with you again.  Dr Ziai: Sure. So again, looking at the MRI, which all patients with ICH should have nowadays. If patients do have these hemorrhagic findings, a lobar ICH, evidence of CSS, cortical superficial siderosis, especially if it's disseminated, and also lobar microbleeds, especially if there are greater than five, if they're multiple, then anticoagulation should really be avoided in those patients.  Dr Albin: Absolutely. So, I'm really hearing that when we have a patient with ICH, it is just critically important that we understand is this a hypertensive bleed or is this a lobar bleed that is probably related to cerebral amyloid angiopathy? And getting to that distinction is going to play a major role in our deciding whether or not the patient can be on DAPT or can be on anticoagulation. And then what are some of the strategies for patients that you're referring them to if they really cannot tolerate being on anticoagulation, but they have atrial fibrillation, and they do need some sort of ischemic stroke prevention?  Dr Shah: There's still a lot of controversy, even in non-lobar hemorrhages, about resuming anticoagulation and when that would be safe. HAF trial, there was a reduction in ischemic stroke recurrence, uh, but a significantly higher increase in hemorrhage recurrences. I think that trial included both deep and lobar hemorrhages. So, we still need more data, and I think the ASPIRE trial and maybe a meta-analysis would answer that eventually. But in the meantime, if a, specifically for lobar hemorrhages, which are, uh, thought to be CAA related, if they, uh, and the patient has AFib, you know, where anticoagulation would be contraindicated, a watchman device or, you know, AFib ablation may be some of the other strategies that can be looked into for those patients specifically.  Dr Albin: Right. I think that's a really important point to emphasize, that we don't just don't give up and say, "Oh, you're not a candidate for anticoagulation," but we really reach out to our cardiovascular friends and say, "Hey, what other procedures can you offer that will minimize the risk of recurrence?" You know, we don't want them to have an ischemic event, but we also know long-term that there would be a real risk of anticoagulation. Just reminder to our listeners that there are new procedures, and our cardiology colleagues are always doing new trials and new devices, and so we should really leverage their expertise here. I am in the final minutes gonna just switch gears a little bit from talking about sort of the nitty-gritty of secondary ischemic prevention and secondary hemorrhagic stroke prevention and thinking about there has been this degree of pessimism around ICH patients, and that, you know, they have a much more severe outcome than our patients with ischemic strokes. I think that that is probably a myth that we need to do some debunking around, and I think maybe we need to reframe in terms of thinking about just the trajectory. So, Dr. Shah, walk us through a little bit about what we can expect about the recovery trajectory in ICH compared to those patients who have an ischemic stroke. Dr Shah: Yes. From some newer data and studies, it is becoming clear that recovery after ICH is much slower than we expect. In general, for ischemic stroke, recovery is measured within the first few weeks to up to 90 days. But in ICH, we now know that patients can keep recovering all the way up to six months and even beyond. In general, from just a, a study of heart recovery that occurs after ischemic stroke, there's a steep recovery in the first seven days, and then sort of after that, patients still continue to recover, but it, it starts plateauing where up to 90 days. Whereas with ICH, there is not much recovery in the first 7 to 30 days, but after that, there is a recovery that occurs significantly between day 30 and day 180, and then some patients continue to recover all the way up to one year. The more severe the hemorrhage, the slower the recovery, but there's still some evidence to suggest that even severe hemorrhage patients can recover all the way up to one year out and beyond. This is, of course, in terms of functional recovery.  Dr Albin: I think that's a really important point for our audience. Many of the listeners are residents, they're fellows, they're seeing these patients in the hospital, and they may not see a whole lot of improvement over even 30 days. But to keep in mind that just because the patient has not had a dramatic recovery within that first month that they may be in the ICU and then on the floor does not mean that that patient will never have recovery, and that we reset our expectations that recovery is possible, it's just gonna be slower. And I think that that's not only important for the healthcare team to take in mind, but also for patients and their families to know there is hope here. It's just gonna be slower. Dr. Ziai, looking ahead, what developments in this are you most excited about that you think will move the needle for care for the long-term outcomes and the prevention for these patients? What's ahead in, in ICH?  Dr Ziai: Yeah, I think the research that's going on is very exciting at the moment. We just saw the presentation at the World Stroke Organization conference in the fall of the TRIDENT trial, Triple therapy prevention of Recurrent intracerebral Disease events, meaning strokes. And these investigators found that a single pill, a fixed dose of three blood pressure-lowering agents actually was successful in significantly reducing the risk of recurrent stroke in patients who have had a history of ICH and have just normal or low-grade hypertension. So rather than having patients on multiple antihypertensive agents, it may be possible to have them on a single pill, and may dramatically reduce their stroke risk. So that's exciting. There is also a trial ongoing, ASPIRING, testing whether antiplatelet monotherapy after 24 hours only can reduce the risk of all serious vascular events in ICH survivors. So very early antiplatelets. The SATURN trial, we didn't talk about statins yet, but it is comparing continuation versus discontinuation of statin therapy in ICH patients. And then we have ongoing epidemiological studies that are really needed to understand this interaction between the cardiovascular prevention strategies, the antithrombotic use, the blood pressure targets, and these high-risk neuroimaging markers for ICH. And I think that's gonna be key, personalizing the interventions for these patients.  Dr Albin: So, I love that. And what I'm hearing is that it's really important to think about the personalized approach as well as how do we simplify things. We know that blood pressure control is critically important to the primary and secondary prevention of ICH, but we have to make it easy for patients to do so. Dr. Shah, I want to end with kind of understanding, you know, this was an unusual topic for neurointensivists to talk about. This was really about prevention. It was about long-term survivorship. It was about not what's happening in the neuro ICU. How did you guys get interested in sort of that aspect of care?  Dr Shah: Yeah, so that's a great question. Dr. Ziai has been my mentor since I was in fellowship, so now about eight years that I've been working with her, and this was a project that I started in fellowship with under her mentorship, looking at long-term recovery in ICH patients, and specifically severe patients. Happy that work has received a lot of recognition. It was published in JAMA Neurology. We looked at patients with severe intracerebral and intraventricular hemorrhage, those that survived with an mRS of four and five at day 30, and what happened to them over the course of the year. There was really not much data on recovery after ICH. And we were very surprised to see that up to 40% of patients that were an mRS of four and five, so really, really severely disabled at day 30, recovered to an mRS of zero to three by one year. About one-third of that group that recovered actually achieved functional independence with an mRS of zero to two, which was very surprising, really breaking the myths around the pessimism with ICH. We found that a lot of the baseline comorbidities like diabetes, white matter disease, as well as what happens to them during the acute hospitalization, were adding all of that information to the severity of the hemorrhage significantly improved our ability to predict long-term recovery after ICH. And so that's kind of how we got interested in this work, looking at how factors in the care that we provide in the ICU, as well as what the patients come in with, how all of that could be modified to promote recovery in these patients that are often been forgotten.  Dr Albin: I think that there's one takeaway to our listeners is that this is really a place where there's a lot of hope for recovery, and that the nihilism that has really surrounded ICH is a thing of the past, and we have to move forward with thinking about how do we proactively impact the recovery and counsel the patients and give them hope. Because just as your research shows, there really is the ability that they can attain that functional independence, which is absolutely astounding. It's really amazing. Again, today I've been interviewing Dr. Wendy Ziai and Dr. Vishank Shah about their article on intracerebral hemorrhage. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Please be sure to check out Continuum Audio episodes from this and other issues. Please go and check out. They have a wonderful article with lots of tables and figures, so much data. And again, thank you to our listeners for joining us today. Thank you, Dr. Ziai and Dr. Shah.  Dr Ziai: Thanks very much.  Dr Shah: Thank you.   Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Rapid advances in acute ischemic stroke care have expanded treatment windows and improved patient outcomes through thrombolysis, mechanical thrombectomy, and optimized antithrombotic strategies. This episode highlights evolving approaches to patient selection, the growing role of tenecteplase, and the importance of team-based systems of care in delivering timely, effective treatment. In this episode, Casey S. Albin, MD, FAAN, speaks with Christopher R. Leon Guerrero, MD, author of the article "Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Leon Guerrero is an associate professor of neurology and the adult neurology residency program director at Atrium Health Carolinas Medical Center in Charlotte, North Carolina, where he also serves as outpatient stroke director. Additional Resources Read the article: Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @caseyalbin Full episode transcript available here Dr Albin: In stroke care, every minute kills nearly two million neurons. But today, we're going to unpack all the details about the latest treatments that can give those neurons back.  Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast.  Dr Albin: Hello and welcome. This is Dr. Casey Albin. Today, I'm interviewing Dr. Christopher Leon-Guerrero about his article on Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast. I always like to start by just having you introduce yourself so our listeners know a little bit about you.  Dr Leon-Guerrero: Thanks for the introduction, Dr. Albin. Really glad to be here today. My name is Chris Leon-Guerrero. I'm a vascular neurologist at Atrium Health in Charlotte, North Carolina, at Carolinas Medical Center. I'm an associate professor in the Department of Neurology. I serve as our Neurology Residency Program Director, and I also wear the hat of an outpatient stroke director in our clinics.  Dr Albin: So, you are wearing a lot of hats and balancing a lot of things, and it's a really exciting time to be talking about this. For our listeners, we are recording this right after the launch of the American Heart Association, American Stroke Association just released their new guidelines on acute ischemic care. So, no better time to kind of dive into some of this. And really, when I think about acute ischemic stroke care, it's dramatically transformed in the last two to three decades. I mean, from lengthening time windows for IV thrombolysis to expanded thrombectomy eligibility, this is really, I think, some of the most exciting stuff in neurology. And your article did a fantastic job of distilling those rapid advancements and clarifying some of the evidence behind some of these new evolving treatment selections and imaging modalities, and it's exciting. So, let's just start with thrombolysis. Where are we now with IV thrombolytics and the time windows there?  Dr Leon-Guerrero: So, a lot has changed in the last decade, since that initial trial with NINDS, nearly thirty years ago. We're still giving intravenous thrombolysis in the traditional time window up to 4.5 hours, and really emphasizing we should be selecting patients for treatment early and quickly as possible. In most of those cases, a non-con head CT is sufficient to rule out bleeding and initiate treatment as quickly as possible. Where things have gotten really exciting is using advanced neuroimaging to help select patients beyond that traditional 4.5 hour window, and we're able to treat patients even up to twenty-four hours from symptom onset.  Dr Albin: Which is really exciting. It has really totally shifted the paradigm here. You know, I think most listeners are going to be pretty familiar with three to four and a half hours. Like, that's sort of our standard. What can you tell us about some of the advanced imaging we're using for that later selection period?  Dr Leon-Guerrero: It's around the principle of you want to be able to, uh, rescue significant salvageable tissue without a lot of core. So, this large profusion deficit and small core is really how you're trying to select out these patients. And two types of modalities are used. One is going to be MRI, and a lot of those imaging protocols, you know, are outlined in the WAKE UP trial and basically are looking for patients with DWI hyperintense lesions and FLAIR negative lesions to suggest that patients in an early time window that's treatable for thrombolysis. And then in the other category, we'll be using profusion imaging, whether that's CT profusion or MR profusion, to look for patients with large salvageable tissue.  Dr Albin: Yeah. And I think that this has been one of the things that, to me, has been really impactful is I think when WAKE UP came out, it was exciting. It was fun to sort of think about, "Hey, we're going to be able to use MRI." But MRI can be very challenging to get acutely, especially in community centers where they don't have the capabilities to get someone from the emergency department into an MRI rapidly enough to make thrombolysis decisions. So, to see some of that expand to CT profusion has been really exciting. How are you going about sort of counseling patients or thinking about their risk when you're using some of those, like, advanced imaging techniques?  Dr Leon-Guerrero: Yeah. I think it's similar to the conversations we've had with patients even within the traditional 4.5 hour window. The risk for intravenous thrombolysis is hemorrhage, and counseling patients on the, you know, the risk and benefits of hemorrhage and the potential clinical benefit of receiving thrombolytics is important. And then providing patients with that information to make an informed decision, so that they can make the best decision for their own care.  Dr Albin: Totally. And it's, again, time sensitive, but trying to give families enough information and enough time to sort of process those, especially when it's a little bit beyond the standard that we're so used to consenting for. The other big area that's really changed is that tenecteplase has become the star of the show. It's really gained momentum, so what should clinicians understand about this?  Dr Leon-Guerrero: Yeah. There's been an explosion of data over the last decade on tenecteplase supporting its use for clinical practice. You know, there was recent updates even from the neurology journal with a large meta-analysis with all of the data showing good clinical outcomes and perhaps even lower risk of bleeding. And so, I think you're seeing a lot of centers across the country switching from alteplase to tenecteplase. There's some practical advantages. So tenecteplase is a one-time bolus dose. And then biologically, it seems to have better fibrin specificity, longer half-life, which may ultimately make it a more attractive drug and may make it even more effective. But I think the practical aspects of tenecteplase are not to be understated. I think there's a lot of advantages for speed and efficiency and for centers to make that switch.  Dr Albin: Yeah. I remember when our health system made the pivot from alteplase to tenecteplase. Like any changes, that obviously created some adjustments with the new workflow. But, the fact that this could be given just as a one-time dose and not with the "we got to calculate the bolus, and now we got to get the infusion on board," like really simplified workflow. So, I think that's been pragmatically one of the nicest things we've done in stroke care. Really exciting.  Dr Leon-Guerrero: Yeah. And, you know, it's a doable thing. I think you have to be, very deliberate about it at whatever center you're at to make sure that all stakeholders are aware of that change. I think that's helpful to get everybody involved and have a lot of planning to avoid wrong dosing errors or inadvertently dosing as alteplase versus tenecteplase. But it's certainly doable, and I think in the long term, centers that have switched have been pretty satisfied with tenecteplase.  Dr Albin: And you know, initially when this came out, there really was sort of a debate about, is it gonna be 0.25? Was it gonna be 0.4? Where have we landed with that debate?  Dr Leon-Guerrero: So, I think we found the correct dose is 0.25 milligrams per kilogram is the recommended dose with a max out of 25 milligrams. There's some within the American Heart Association guidelines that were just published. They mentioned even tier dosing based on 10 kilograms, so intervals. So, that may be an easier way for centers to do it. But that cap out dose of 25 milligrams at 0.25 milligrams per kilogram, I think, is the sweet spot.  Dr Albin: Yeah. That's great, and I think that that has helped, you know, say, "This is what we're doing. There's not a debate that's happening anymore." And that really just got codified in the new ASA guidelines, so really exciting there. So, there is a lot of guidance for these patients, but I think one of the things that your article really tackled is the fact that there are some special populations, where we really still don't have a lot of guidance. And so, I think just to kind of distill those for the listeners, thinking about our pregnant patients, thinking about children, how are we approaching thrombolysis decisions in these special populations?  Dr Leon-Guerrero: These are always tough cases. For example, for pregnant women, they've often been excluded in the thrombolytic trials. But there's still evidence. You know, there's some inference based on the evidence we do have, and there's a lot of registry and case reports suggesting potential safe treatment for pregnant women. And I think when you're approaching those cases, again, it's gonna be patient-centered and really should be multidisciplinary. These are the types of cases you really need to lean on your maternal fetal medicine colleagues, your high-risk OBGYNs, your obstetricians to help with that decision-making. And I think, a multidisciplinary approach is the way to go for these cases. It's the same thing with the pediatric population. We had some data. There was one trial, randomized control trial, called TIPS trial that looked at using intravenous alteplase for acute ischemic stroke in patients under the age of 18. It had difficulty with enrollment. But I think most experts would argue that patients with pediatric stroke should be considered for intravenous thrombolysis if appropriate. Again, same thing. You want to make it a multidisciplinary approach, really getting your pediatric neurologists, your pediatricians involved early to make the best decision for the patient.  Dr Albin: Yeah. That's just really an important takeaway, just thinking about this as a multidisciplinary decision, because there are going to be other stakeholders to the patient's care who may have some different information than what we as neurologists are bringing to the approach. And obviously, our perspective really matters. But trying to work in everyone's unique vantage point of the patient really helps to make the most effective decision. When we talk about acute ischemic stroke care, I really don't think that you could do justice to the topic without pivoting to mechanical thrombectomy, which, you know, as we think about how the medical field as a whole, not just neurology, how the medical field has evolved. I mean, there's probably no bigger impact than mechanical thrombectomy has made in terms of reducing not just morbidity, but mortality from stroke. I mean both. So, thrombectomy has been around for a while, but just walk our listeners through what's the core that we for sure know that these are the patients that this works for?  Dr Leon-Guerrero: The types of patients we should be selecting for intervention are patients with large vessel occlusions. And those initial trials that were published in 2015 really demonstrated that this is a quite an effective treatment for patients with large vessel occlusion ischemic strokes in the anterior circulation. When that smattering of publications occurred in 2015, the general consensus, we should be treating all patients up to six hours from symptom onset if they do have a large vessel occlusion. And then, Dr. Albin, as you know, the, the windows continue to expand. So, we were using advanced neuroimaging with MR selection and perfusion selection based on DAWN and DEFUSE 3 trial protocols to select patients all the way out to the 24 window, and it's even expanded beyond that over the last few years.  Dr Albin: I think that when we think about trials that really, totally, changed the game, when we think about DAWN and DEFUSE 3, and we switched from that time-based window to more of that, like we talked about for thrombolysis, that tissue-based clock and, like, looking at what is salvageable and where can we make an impact on salvageable tissue, truly moved the needle in terms of just bringing this therapy for people who, you know, it's hard to get in within six hours. When we moved the needle to 24, it made a huge difference. But people were still coming in with a lot of ischemic damage already done, and they would have traditionally been excluded from being enrolled in thrombectomy trials. But that's changing too. So where are we there?  Dr Leon-Guerrero: Yeah. I think there were lessons learned from DEFUSE and DAWN that we were probably over-selecting. Perhaps too stringent. You know, we had number needed to treat in the range of two to three for good outcome based on those trials. And so, I think those were lessons learned to move forward, and we, and, and people started looking at large core infarctions. And in the last few years, we've seen a multitude of randomized control trials examining large core infarctions. These are patients with ASPECT scores all the way down to zeros. A lot of the trials relied on three to six as their score, but there was at least one large core study that looked at ASPECT scores down to zero to two, and all of these studies showing benefit.  Dr Albin: Yeah. And we've really moved into if there's some tissue to spare there, probably getting clot out really makes a big difference in impact. You know, it was really surprising to me as a neurointensivist looking at these trials, that the trials had such low rates of hemorrhage, and pretty low rates of dramatic cerebral edema after thrombectomy. I don't know that we've seen all of that in sort of real world applications, but again, we are still seeing some of these patients come in, that really would've been devastated having some amount of functional recovery regained, which is incredible. In terms of another patient population that I think gives a lot of people pause or stickiness, is those basilar artery occlusions, right? Another large vessel, but one that we've had a little bit harder of a time enrolling in trials and having well-selected trials. Where are we now on whether or not basilar artery occlusion should go to mechanical thrombectomy?  Dr Leon-Guerrero: So, a lot of excitement in this area, too. There's at least two studies that were published in the last five years that were showing benefit in doing thrombectomy for patients with basilar artery occlusion up to 24 hours, and these were patients with moderate to severe deficits with NIH Stroke Scale scores greater than 10. And then making sure that they don't have large core, so using a newer scoring algorithm on the CAT scan called PC ASPECT, so basically a posterior circulation ASPECT score, to kind of make sure that patients don't have large core infarctions that are being considered for thrombectomy. All of those things collectively in those two recent studies, the ATTENTION trial and the BAOCHI trial, I think is what ended up making those studies positive, is that we were selecting the right types of patients, uh, without large core, early core, and patients with moderate to severe deficits that made the difference from previous trials.  Dr Albin: Yeah. I think that that's so important. Those trials to me, and like how long it took to get those enrolled, really emphasized to me that there really was a selection bias. Like, we believed this worked, which made it hard to then do a trial. But I'm so glad to hear that we have the data now to support moving forward in a more rigorous way.  Dr Leon-Guerrero: You're absolutely right. I think that was some of the challenges with the initial trials. In fact, the authors had commented on that. There's a lot of difficulties with lack of clinical equipoise, or experts wanting to take these patients anyways out of clinical trial and treat them, and so that's always been an issue. And then, you know, we all remember basilar artery occlusion cases. They can be severe, devastating cases in our career, but the reality is they're not that common. So, if you look at large vessel occlusions, they only account for about 10%, and if you look at all stroke patients presenting to most centers, they represent about 1% of cases. So really hard clinical trials to do just because there's thankfully not a lot of patients walking around with basilar artery occlusions, but certainly makes for challenges when you're trying to conduct randomized controlled trials on this subset of patients.  Dr Albin: Absolutely. But we did it, and I think that, like, really if, if the listeners take nothing else, it's that the field of vascular neurology is really moving forward with evidence-based, doing very rigorously controlled clinical trials, which is, I think, is what makes this field so exciting. Finally, closing out, cause we could talk all day, but we don't have all day. You know, it seems to me that more and more we are just using dual antiplatelet therapy all the time. And maybe that is, uh, a little bit of a hyperbole, cause I don't think it's all the time, but let's walk through— when is there good evidence for dual antiplatelet therapy?  Dr Leon-Guerrero: Yeah. So, there's strong evidence for early initiation of dual antiplatelet therapy or DAPT in patients with minor stroke or high-risk TIAs, and it's been studied using both clopidogrel as an add-on to aspirin and ticagrelor. Both seem like they're viable options in patients. I think one of the key things is the duration of therapy. So, in these cases with minor stroke and high-risk TIAs, we really should be confining the treatment of early DAPT for 21 days. The risk profile changes, so the risk of recurrent stroke starts to decline with time, and that risk of hemorrhage complications increases with time. And so that sweet spot of 21 days, or even some centers will do 30 days for just practical purposes, you know, really is what we should be doing in most of those cases. Other instances where DAPT can be considered, is in patients with intracranial atherosclerosis that's symptomatic, extrapolating from the SAMMPRIS trial that in the, in the medical management arm alone, used dual antiplatelet therapy with aspirin and clopidogrel for up to 90 days. So, you'll see that as well in clinical practice. Some people will opt for a 90-day duration for those patients with symptomatic intracranial atherosclerosis and stroke.  Dr Albin: Just so I emphasize, this is not set it and forget it. You can stay on DAPT forever. It is you're going to have a definitive time course, 21 days, 90 days. We have directed instructions where we're doing more benefit than harm because of that risk of hemorrhage.  Dr Leon-Guerrero: That's correct. In most cases, we really should be confining the duration of DAPT either to 21 days or 90 days. This is a challenging clinical practice. Centers really have been making an emphasis on stroke follow-up, so making sure these patients get appropriate and timely stroke follow-up to address these issues and to make sure that DAPT is discontinued if appropriate.  Dr Albin: Yeah. I love that, and I want to pull on that a little bit because you as someone who is helping direct a stroke center– A lot of this really does rely on systems of care. When we think about early lysis decisions or mechanical thrombectomy, it's how do we get the patient to one of those capable centers as quickly as possible? And then on the back end, when you're discharging a patient, how do you make sure that they are getting follow-up, making sure that they're getting their Holter monitor if they need it? You know, all the stuff that goes into kind of figuring out, why did the stroke happen? What are some of the things that you, in your role, are really excited about, that will move the needle over the next five or 10 years?  Dr Leon-Guerrero: Yeah. I think a lot of centers are doing it just like we're doing it. It really has to be a team-based approach, and you really want to reach the patient where they are in terms of the continuum of care. And so making sure if it's the in the field that you've reached out to your EMS and first responders to make sure they understand triage protocols to get patients where they need to be, to get the acute treatments that they need for the type of stroke that they're presenting with, to the actual centers that you work at, making sure your whole team, nurses, emergency physicians, APPs that are involved in care are all aware of the stroke protocols and how we're selecting these patients, making sure that your imaging protocols are up to date, and so that it's seamless when patients come in, that we're not adding on perfusion if we should have gotten that up front– We already know, have made decisions before that patient gets there. And then thinking about the patient after that hospital stay, I think, is critical. We really want to reduce their risk of recurrence, making sure that we're leveraging transitions of care, getting those patients seen in our stroke clinics for follow-up, and then make sure we're passing that baton to the long term. All of their long-term comorbidities that may be increasing their risk of stroke are managed and reduced as best as possible.  Dr Albin: From the Continuum journal to the continuum of stroke care.  Dr Leon-Guerrero: That's right.  Dr Albin: I mean, we have it all. I think that that really is so important. I'll just close with what's one thing that is your favorite part about being a vascular neurologist?  Dr Leon-Guerrero: I think it's what attracted to me to this field. As a medical student at that time, all we had was intravenous thrombolysis, and there was so much promise. There was so much promise that there was going to be widespread advancements in acute stroke, and here we are. There's been a tremendous amount of advancements and improvements for patients. I'm really excited to see what unfolds in the next few years, and I'm really excited that we've been able to increase the number of patients we're able to treat with acute ischemic stroke. I hope that we continue to expand the time window, the inclusion criteria, all of those things that we can treat more stroke patients effectively.  Dr Albin: It is really a very exciting time to be a vascular neurologist. Again, today, I've been interviewing Dr. Christopher Leon-Guerrero about his article on Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Be sure to check out Continuum Audio episodes from this and other issues, and thank you again, Dr. Leon Guerrero and our listeners for joining today.  Dr Leon-Guerrero: Thanks for having me.  Dr Monteith: This is Dr. Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

The JournalFeed podcast for the week of June 22-26, 2026.These are summaries from just 2 of the 5 articles we cover every week! For access to more, please visit JournalFeed.org for details about becoming a member.Thursday's Spoon Feed:Tirofiban resulted in greater 90-day excellent neurological outcomes vs. placebo in patients with no medium or large vessel occlusion (LVO) who were not improving with with tenecteplase (TNK), NNT = 9.Friday's Spoon Feed:Dual antiplatelet therapy (DAPT) with ticagrelor plus aspirin vs. placebo in patients with stroke treated with thrombolysis resulted in better 90-day excellent neurological outcome, NNT = 15, without a significant increase in symptomatic intracranial hemorrhage (sICH).

Witam Państwa, nazywam się Jarosław Drożdż, pracuję w Centralnym Szpitalu Klinicznym Uniwersytetu Medycznego w Łodzi, skąd nagrywam podcast Kardio Know-How. W tym odcinku omawiam drugą część badań opublikowanych podczas kongresu ACC 2026. Tegoroczny kongres ACC w Nowym Orleanie przyniósł niezwykle interesujące doniesienia dotyczące przewlekłych zespołów wieńcowych, a szczególną uwagę zwróciły dwa duże badania z Korei Południowej dotyczące leczenia pacjentów ponad rok po zawale serca. Pierwsze z nich, SMART DECISION, opublikowane równolegle w NEJM: https://www.nejm.org/doi/full/10.1056/NEJMoa2601005, sugeruje, że u wyselekcjonowanych pacjentów po zawale serca z zachowaną frakcją wyrzutową i bez niewydolności serca odstawienie β-adrenolityku może nie pogarszać rokowania. Wyniki te wzbudziły ogromne zainteresowanie, ale jednocześnie wiele wątpliwości, ponieważ badana populacja była wyjątkowo zdrowa, miała bardzo niską śmiertelność i znacząco różniła się od populacji europejskiej, zarówno pod względem BMI, genetyki, jak i profilu ryzyka. Dlatego mimo medialnego entuzjazmu nadal obawiam się, że bezrefleksyjne odstawianie β-adrenolityków w naszej populacji może przynieść więcej szkód niż korzyści i pozostaję zwolennikiem ich utrzymywania po zawale serca, podobnie jak mówiłem wcześniej w podcastach: https://open.spotify.com/episode/66lI4H45oK0PsFeXNN3hAx?si=04412e4ab3fe4e5a oraz https://open.spotify.com/episode/1H4KdTnpGGYLqBRdW81xRw?si=e0699442be3446b5. Drugim niezwykle ważnym tematem było badanie HOST-EXAM i jego 10-letnia obserwacja, opublikowana w Lancet: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(26)00422-8/fulltext, pokazująca przewagę monoterapii klopidogrelem nad klasycznym leczeniem ASA po zakończeniu DAPT. W badaniu wykazano prawie 40% redukcję ostrych zespołów wieńcowych, niemal 50% redukcję udarów mózgu oraz wyraźne zmniejszenie ciężkich krwawień przy stosowaniu klopidogrelu zamiast ASA. Wyniki te potwierdzają wcześniejsze obserwacje i coraz mocniej podważają tradycyjny pogląd, że po zakończeniu DAPT naturalnym wyborem musi być wyłącznie ASA. Mimo że coraz częściej spotykam pacjentów prowadzonych wyłącznie na klopidogrelu i sam zaczynam akceptować takie podejście, nadal widzę praktyczne problemy związane z nagłymi zabiegami chirurgicznymi, urazami czy samodzielnym dokładaniem ASA przez pacjentów, którzy od lat słyszeli, że „aspiryna po zawale musi być zawsze”. Dlatego w 2026 roku w przewlekłych zespołach wieńcowych nadal utrzymuję β-adrenolityki po zawale serca, ale jednocześnie coraz wyraźniej dryfuję w kierunku monoterapii klopidogrelem zamiast ASA, obserwując jak szybko zmienia się współczesna kardiologia. Szczegółowy TRANSKRYPT do odcinka.Podcast jest przeznaczony wyłącznie dla osób z profesjonalnym wykształceniem medycznym.

In this episode, we review key updates from the 2026 AHA/ASA Guideline for the Early Management of Patients With Acute Ischemic Stroke, including changes to IV thrombolysis, antiplatelet therapy, endovascular treatment, blood pressure goals, and glycemic goals. Key Concepts Tenecteplase (TNKase) is now equally preferred to alteplase (Activase) by the 2026 AHA/ASA guidelines. Tenecteplase has several advantages related to administration and the risk of medication errors. IV thrombolysis can be given in selected patients up to 9 hours after stroke symptom onset depending on brain imaging findings. Patients with symptom onset less than 4.5 hours are still eligible for IV thrombolysis regardless of brain imaging findings. IV thrombolysis should not be given for mild, non-disabling stroke symptoms. A "non-disabling" stroke means the symptoms do not impair activities of daily living or ability to return to work. The criteria for dual antiplatelet therapy (DAPT) has been updated. DAPT can be given for NIHSS of 4 or 5 (not just 3 or less) and can be started up to 72 hours after stroke onset (not just within 24 hours). References Prabhakaran S, Gonzalez NR, Zachrison KS, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. Published online January 26, 2026. doi:10.1161/STR.0000000000000513

Witam Państwa, nazywam się Jarosław Drożdż, pracuję w Centralnym Szpitalu Klinicznym Uniwersytetu Medycznego w Łodzi, skąd nagrywam podcast Kardio Know-How. W tym odcinku omawiam efekty połączenia leków hamujących krzepnięcie krwi.Po zawale ściany przedniej skrzeplina w lewej komorze występuje obecnie u 9–12% chorych (a w NMR nawet u ponad 16%), podczas gdy w erze przedtrombolitycznej sięgała 60%. Rezonans magnetyczny wykrywa skrzepliny nawet czterokrotnie częściej niż echo, a tylko około 1/3 zmian widoczna jest w badaniu echokardiograficznym. Link do pełnej wersji artykułu state of the art z roku 2022: https://www.jacc.org/doi/10.1016/j.jacc.2022.01.011Ticagrelor zmniejsza częstość skrzeplin względem klopidogrelu, dlatego pozostaje preferowanym składnikiem DAPT. W badaniu APERITIF opublikowanym 25 lutego 2026 w JAMA Cardiology oceniono dodanie naczyniowej dawki riwaroksabanu (2 × 2,5 mg) do DAPT po zawale ściany przedniej.https://jamanetwork.com/journals/jamacardiology/fullarticle/2845590W nowej analizie (ok. 560 pacjentów) redukcja skrzeplin była niewielka i statystycznie nieistotna (poniżej 14% vs >16%), przy większej liczbie głównie drobnych krwawień (BARC 1). Mimo częstego występowania skrzeplin zdarzenia zatorowe były rzadkie (ok. 1–1,5%), a śmiertelność poniżej 1%. W praktyce oznacza to, że rutynowe NMR ani dodawanie riwaroksabanu do DAPT z ticagrelorem tuż po zawale nie wydają się uzasadnione, a kluczowe pozostaje stosowanie skutecznej DAPT.Szczegółowy TRANSKRYPT do odcinka.Podcast jest przeznaczony wyłącznie dla osób z profesjonalnym wykształceniem medycznym.

A phase 3 trial in The New England Journal of Medicine found that the oral PCSK9 inhibitor enlicitide reduced LDL by 57% at 24 weeks in high-risk patients, with similar adverse events to placebo. An oral option may improve uptake and help more patients reach lipid targets. In The Lancet, SMART-CHOICE 3 showed clopidogrel monotherapy after DAPT post-PCI reduced death, MI, or stroke versus aspirin, without more bleeding. Finally, a large meta-analysis confirmed most reported statin side effects are not causally linked, reinforcing their strong benefit–risk profile.

Host: Emer Joyce Guest: Steffen Massberg Want to watch that extended interview on https://esc365.escardio.org/event/2178?resource=interview Go to: Want to watch that episode? Go to: https://esc365.escardio.org/event/2178   Disclaimer  ESC TV Today is supported by Bristol Myers Squibb and Novartis through an independent funding. The programme has not been influenced in any way by its funding partners. This programme is intended for health care professionals only and is to be used for educational purposes. The European Society of Cardiology (ESC) does not aim to promote medicinal products nor devices. Any views or opinions expressed are the presenters' own and do not reflect the views of the ESC. The ESC is not liable for any translated content of this video. The English language always prevails.   Declarations of interests Emer Joyce and Steffen Massberg have declared to have no potential conflicts of interest to report.

This episode covers: Cardiology This Week: A concise summary of recent studies DAPT: how short is too short Obesity and atrial fibrillation Milestones: COURAGE  Host: Emer Joyce Guests: Carlos Aguiar, Steffen Massberg, Prash Sanders Want to watch that episode? Go to: https://esc365.escardio.org/event/2178 Want to watch that extended interview on dual antiplatelet therapy (DAPT) and shortening its optimal duration, go to: https://esc365.escardio.org/event/2178?resource=interview   Disclaimer  ESC TV Today is supported by Bristol Myers Squibb and Novartis through an independent funding. The programme has not been influenced in any way by its funding partners. This programme is intended for health care professionals only and is to be used for educational purposes. The European Society of Cardiology (ESC) does not aim to promote medicinal products nor devices. Any views or opinions expressed are the presenters' own and do not reflect the views of the ESC. The ESC is not liable for any translated content of this video. The English language always prevails.   Declarations of interests Stephan Achenbach, Yasmina Bououdina, Emer Joyce, Nicolle Kraenkel and Steffen Massberg have declared to have no potential conflicts of interest to report. Carlos Aguiar has declared to have potential conflicts of interest to report: personal fees for consultancy and/or speaker fees from Abbott, AbbVie, Alnylam, Amgen, AstraZeneca, Bayer, BiAL, Boehringer-Ingelheim, Daiichi-Sankyo, Ferrer, Gilead, GSK, Lilly, Novartis, Pfizer, Sanofi, Servier, Takeda, Tecnimede. John-Paul Carpenter has declared to have potential conflicts of interest to report: stockholder MyCardium AI. Davide Capodanno has declared to have potential conflicts of interest to report: Bristol Myers Squibb, Daiichi Sankyo, Sanofi Aventis, Novo Nordisk, Terumo. Konstantinos Koskinas has declared to have potential conflicts of interest to report: honoraria from MSD, Daiichi Sankyo, Sanofi. Steffen Petersen has declared to have potential conflicts of interest to report: consultancy for Circle Cardiovascular Imaging Inc. Calgary, Alberta, Canada. Prashanthan Sanders has declared to have potential conflicts of interest to report: advisory board representative University of Adelaide, Medtronic, Boston Scientific, CathRx, Abbott and Pacemate as well as research grants for University of Adelaide: Medtronic, Abbott, Boston Scientific, Becton Dickson. Emma Svennberg has declared to have potential conflicts of interest to report: Abbott, Astra Zeneca, Bayer, Bristol-Myers, Squibb-Pfizer, Johnson & Johnson.

Host: Emer Joyce Guest: Steffen Massberg Want to watch that extended interview on https://esc365.escardio.org/event/2178?resource=interview Go to: Want to watch that episode? Go to: https://esc365.escardio.org/event/2178   Disclaimer  ESC TV Today is supported by Bristol Myers Squibb and Novartis through an independent funding. The programme has not been influenced in any way by its funding partners. This programme is intended for health care professionals only and is to be used for educational purposes. The European Society of Cardiology (ESC) does not aim to promote medicinal products nor devices. Any views or opinions expressed are the presenters' own and do not reflect the views of the ESC. The ESC is not liable for any translated content of this video. The English language always prevails.    Declarations of interests Emer Joyce and Steffen Massberg have declared to have no potential conflicts of interest to report.

O NEO-MINDSET, estudo 100% brasileiro e multicêntrico, foi um dos principais destaques da ESC 2025 e trouxe uma das perguntas mais polêmicas do ano:

Dr. Natalie Bodmer, member of the ACE editorial board,  joins Dr. Adam Striker to discuss new guidelines regarding the perioperative cardiovascular management of patients undergoing noncardiac surgery (NCS). Learn about optimal timing of elective or time-sensitive NCS for prior percutaneous coronary intervention (PCI). Topics include the management of dual antiplatelet therapy (DAPT), what researchers have learned, and more. Recorded September 2025. 

DAPT-SHOCK-AMI Trial: Cangrelor in Cardiogenic Shock

Listen in as our expert panel discusses the latest recommendations for managing medications after heart attacks and other cardiac events. You'll hear our panelists review which antiplatelets to use, the optimal blood pressure meds, and the role of statin and non-statin cholesterol meds.Special guests:Danielle Blais, PharmD, FCCP, BCCP, BCPSCardiology Lead Specialty Practice PharmacistRichard M. Ross Heart HospitalThe Ohio State University Wexner Medical CenterJoel C. Marrs, PharmD, MPH., BCACP, BCCP, BCPS, FAHA, FASHP, FCCP, FNLAProfessor and Coordinator of Clinical OutreachThe University of Tennessee Health Science CenterDepartment of Clinical Pharmacy & Translational ScienceYou'll also hear practical advice from panelists on TRC's Editorial Advisory Board:Andrea Darby-Stewart, MDAssociate Director, Honor Health Family Medicine Residency ProgramClinical Professor of Family, Community & Occupational MedicineThe University of Arizona College of Medicine – PhoenixCraig D. Williams, PharmD, FNLA, BCPSClinical Professor of Pharmacy PracticeOregon Health and Science UniversityNone of the speakers have anything to disclose. This podcast is an excerpt from one of TRC's monthly live CE webinars, the full webinar originally aired in July 2025.TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist's Letter, Pharmacy Technician's Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.Claim CreditThe clinical resources mentioned are part of a subscription to Pharmacist's Letter, Pharmacy Technician's Letter, and Prescriber Insights: Dual Antiplatelet Therapy for Coronary Artery DiseaseComparison of Oral Beta-BlockersAngiotensin Receptor Blockers and Angiotensin-Converting Enzyme InhibitorsCholesterol Guidelines (United States)Non-Statin Lipid-Lowering AgentsSend us a textIf you're not yet a subscriber, find out more about our product offerings at trchealthcare.com. Follow, rate, and review this show in your favorite podcast app. Find the show on YouTube by searching for ‘TRC Healthcare' or clicking here. You can also reach out to provide feedback or make suggestions by emailing us at ContactUs@trchealthcare.com.

In this episode  of JACC This Week, Editor-in-Chief Dr. Harlan Krumholz explores device safety, abbreviated DAPT, drug-coated balloons, and a novel surgical polymer valve. Plus: expert insights on cardiovascular innovation, obesity management, fellowship signaling, and more.

Hosts Mitsuaki Sawano, MD, Kentaro Ejiri, MD, and Nobuhiro Ikemura, MD, welcome Yuki Obayashi, MD, of Leiden University Medical Center, to discuss findings from the STOPDAPT-3 trial. Dr. Obayashi highlights that, among ACS patients—including those with HBR or STEMI—aspirin and clopidogrel monotherapy after 1 month of DAPT resulted in similar rates of ischemic and bleeding events. These results support flexible, patient-centered antiplatelet strategies beyond the acute phase.

JACC's June 10 dedicated issue on the ACS guidelines, author and former JACC Editor-in-Chief Valentin Fuster, MD, PhD, MACC, speaks with current JACC Deputy Editor Rasha Al-Lamee, MD concerning the recent ACC/AHA ACS guidelines. Dr. Fuster speaks to this comprehensive update aligning more closely with international (especially ESC) standards in acute coronary syndrome care. The interview and accompanying commentary publishing in the June 10 issue speaks to the importance of improved methodological rigor, global stakeholder inclusion, and alignment in key recommendations (e.g., DAPT duration), while also allowing greater transparency in controversial decisions and envisioning the potential for a future universal ACS guideline.

When SAPT or DAPT for PCI

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances, discusses a recently published original research paper on Sex Differences in the Safety and Efficacy of Different Durations of DAPT After PCI

Será que a recomendação clássica de 12 meses de DAPT após SCA ou angioplastia ainda faz sentido? Neste episódio, exploramos as evidências mais recentes que questionam essa prática tradicional.✅ O que você vai ouvir: • Diferenças entre os principais inibidores do P2Y12 (clopidogrel, prasugrel e ticagrelor) • Quando encurtar, descalonar ou estender a DAPT com base nos principais Trials • Como avaliar o risco de sangramento (Scores PRECISE-DAPT e DAPT)• Terapia tripla em pacientes com fibrilação atrial e necessidade de anticoagulaçãoVamos discutir de forma prática e baseada em evidências quando a DAPT pode ser encurtada ou estendida — e o impacto direto dessas decisões nos desfechos do paciente.

This episode covers: Cardiology This Week: A concise summary of recent studies Dual antiplatelet therapy in 2025 Optimal communication with patients Snapshots Host: Emer Joyce  Guests: Carlos Aguiar, Michelle Kittleson, Gilles Montalescot Want to watch that episode? Go to: https://esc365.escardio.org/event/1798   Disclaimer ESC TV Today is supported by Bristol Myers Squibb. This scientific content and opinions expressed in the programme have not been influenced in any way by its sponsor. This programme is intended for health care professionals only and is to be used for educational purposes. The European Society of Cardiology (ESC) does not aim to promote medicinal products nor devices. Any views or opinions expressed are the presenters' own and do not reflect the views of the ESC.   Declarations of interests Stephan Achenbach, Emer Joyce, Michelle Kittleson and Nicolle Kraenkel have declared to have no potential conflicts of interest to report. Carlos Aguiar has declared to have potential conflicts of interest to report: personal fees for consultancy and/or speaker fees from Abbott, AbbVie, Alnylam, Amgen, AstraZeneca, Bayer, BiAL, Boehringer-Ingelheim, Daiichi-Sankyo, Ferrer, Gilead, GSK, Lilly, Novartis, Pfizer, Sanofi, Servier, Takeda, Tecnimede. Davide Capodanno has declared to have potential conflicts of interest to report: Bristol Myers Squibb, Daiichi Sankyo, Sanofi Aventis, Novo Nordisk, Terumo. Gilles Montalescot has declared to have potential conflicts of interest to report: research funds for Action Groupe or honoraria from Abbott, Amgen, AstraZeneca, Bayer, BMS, Boehringer-Ingelheim, Celecor, CSL Behring, Hexacath, Idorsia, Lilly, Novo Nordisk, Pfizer, SMT, Terumo. Steffen Petersen has declared to have potential conflicts of interest to report: consultancy for Circle Cardiovascular Imaging Inc. Calgary, Alberta, Canada. Emma Svennberg has declared to have potential conflicts of interest to report: Abbott, Astra Zeneca, Bayer, Bristol-Myers, Squibb-Pfizer, Johnson & Johnson.

Host: Emer Joyce Guest: Gilles Montalescot Want to watch that extended interview? Go to: https://esc365.escardio.org/event/1798?resource=interview   Disclaimer ESC TV Today is supported by Bristol Myers Squibb. This scientific content and opinions expressed in the programme have not been influenced in any way by its sponsor. This programme is intended for health care professionals only and is to be used for educational purposes. The European Society of Cardiology (ESC) does not aim to promote medicinal products nor devices. Any views or opinions expressed are the presenters' own and do not reflect the views of the ESC. Declarations of interests Stephan Achenbach, Emer Joyce and Nicolle Kraenkel have declared to have no potential conflicts of interest to report. Carlos Aguiar has declared to have potential conflicts of interest to report: personal fees for consultancy and/or speaker fees from Abbott, AbbVie, Alnylam, Amgen, AstraZeneca, Bayer, BiAL, Boehringer-Ingelheim, Daiichi-Sankyo, Ferrer, Gilead, GSK, Lilly, Novartis, Pfizer, Sanofi, Servier, Takeda, Tecnimede. Davide Capodanno has declared to have potential conflicts of interest to report: Bristol Myers Squibb, Daiichi Sankyo, Sanofi Aventis, Novo Nordisk, Terumo. Gilles Montalescot has declared to have potential conflicts of interest to report: research funds for Action Groupe or honoraria from Abbott, Amgen, AstraZeneca, Bayer, BMS, Boehringer-Ingelheim, Celecor, CSL Behring, Hexacath, Idorsia, Lilly, Novo Nordisk, Pfizer, SMT, Terumo. Steffen Petersen has declared to have potential conflicts of interest to report: consultancy for Circle Cardiovascular Imaging Inc. Calgary, Alberta, Canada. Emma Svennberg has declared to have potential conflicts of interest to report: Abbott, Astra Zeneca, Bayer, Bristol-Myers, Squibb-Pfizer, Johnson & Johnson.

N Engl J Med 2016;375:1242-1252Background: The first drug-eluting stent (DES) was approved by the FDA in 2003 following the publication of the RAVEL trial. Since then, newer generations of DES were developed and were tested in clinical trials. The majority of trials comparing DES to bare-metal stents (BMS) showed reduction in repeat revascularization with DES but no significant reduction in death or myocardial infarction. Following these publications, the use of DES grew rapidly and was used in more than two thirds of percutaneous coronary interventions (PCI) by 2010.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.These trials, however, were very selective, had short follow up time (TAXUS-IV followed patients for 9 months and SPRIT IV followed patients for 12 months), and had limited power to assess hard outcomes.The NORSTENT trial investigators sought to compare DES to BMS in a more pragmatic design and follow patients for longer time.Patients: All patients who were undergoing PCI in Norway were assessed for enrollment. Patients had stable angina or acute coronary syndrome. Lesions were in native coronary arteries or bypass grafts.Patients were excluded if they had prior coronary stents, bifurcating lesions requiring a two-stent technique or life expectancy less than 5 years due to a medical condition other than coronary artery disease. Patients were also excluded if they had contraindications to dual antiplatelets or were taking warfarin.Baseline characteristics: The trial randomized 9,013 patients – 4,504 randomized to receive a DES and 4,509 to receive a BMS.The average age of patients was 63 years and 75% were men. Approximately 42% had hypertension, 54% had hyperlipidemia, 10% had prior myocardial infarction, 7% had prior CABG, 12% had diabetes, and 35% were current smokers.The indication for PCI was stable angina in 29% of the patients, unstable angina in 12% and STEMI or NSTEMI in 58%.Procedures: The study was open-label but outcomes assessment was blinded. Patients were randomly assigned in a 1:1 ratio to receive DES or BMS. Patients could receive several stents as clinically indicated but can only receive the assigned stent type during the index procedure.In all patients, aspirin 75 mg daily was given indefinitely while clopidogrel 75 mg daily was given for 9 months.Follow up visits were done as clinically appropriate without specification from the study protocol. Similarly, no routine follow up coronary angiography was performed.Endpoints: The primary outcome was a composite of all-cause death or spontaneous myocardial infarction. Secondary outcomes included repeat revascularization, stent thrombosis, major bleeding and health status based on the Seattle Angina Questionnaire.Clinical outcomes were collected by linking each patient unique national identification number to the Norwegian national patient registry.Analysis was performed based on the intention-to-treat principle. The study planned to enroll 8,000 patients to be followed for a median of 5 years. Assuming the 5-year event rate of the primary outcome to be 17%, the study would provide 93% power to detect 3% absolute risk difference between the study groups (rate ratio: 1.18). Due to lower than expected mortality, the sample size was increased to 9,000 patientsResults: Among the 20,663 patients who were assessed for eligibility, 12,425 met inclusion criteria. Among patients who met inclusion criteria, 9,013 were randomized. Figure 1 in the manuscript provides details for excluding patients and for not randomizing patients who met eligibility criteria. The most common reason for exclusion was prior PCI.The number of stents implanted per patient was 1.7 and more than 98% received the assigned stent type. The median follow up time was 5 years.The primary composite outcome of all-cause death or nonfatal spontaneous myocardial infarction was not significantly different between both treatment arms (16.6% with DES vs 17.1% with BMS, HR: 0.98; 95% CI: 0.88 - 1.09; p= 0.66).For the secondary outcomes – Hospitalization for unstable angina was similar between treatment groups (5.2% vs. 5.7%; p= 0.21). Stent thrombosis was lower with DES (0.8% vs 1.2%; p= 0.05). Target-lesion revascularization was also lower with DES (5.3% vs 10.3%; p< 0.001). Bleeding Academic Research Consortium (BARC) 3, 4 or 5 was similar between groups (5.5% vs 5.6%; p= 0.88).There was no significant difference in health status based on the Seattle Angina Questionnaire.There were no significant subgroup interactions.Conclusion: In patients undergoing PCI, the use of DES did not reduce the composite endpoint of death or spontaneous myocardial infarction compared to BMS. Target-lesion revascularization was reduced with DES with a number needed to treat of 20 patients.The findings of this study align with the results of other trials comparing DES to BMS. We have reviewed several key trials and included links to additional studies in this field below. Overall, DES significantly reduce target-lesion revascularization without significant effect on all-cause mortality or myocardial infarction.An important consideration in this and other related trials is that both stent types were studied using similar durations of dual antiplatelet therapy (DAPT) following PCI. For patients with stable angina, BMS typically require only one month of DAPT, while DES often necessitate three to twelve months. Since shorter durations of DAPT are generally safer for patients, a trial comparing DES with three to twelve months of DAPT compared to BMS with one month of DAPT would be insightful.A final teaching point is that less than 50% of screened patients were ultimately enrolled in this pragmatic trial, which had minimal exclusion criteria. It's not uncommon for trials to enroll less than 5% of screened patients which limits their external validity.* Other trials of DES vs BMShttps://pubmed.ncbi.nlm.nih.gov/21080780/https://pubmed.ncbi.nlm.nih.gov/22951305/Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

What if the future of dual antiplatelet therapy (DAPT) could be shorter, safer, and more effective? Uncover the latest insights into drug-eluting stents and how they are transforming how we think about dual-antiplatelet therapy. Join us as we examine the game-changing recommendations from top cardiology societies, which suggest that newer-generation stents can significantly reduce the duration of DAPT, particularly for patients with a high bleeding risk. Listen in as we dissect the innovative tools like the PRECISE-DAPT score and ARC-HBR criteria used to determine bleeding risk, ensuring patient safety without compromising on the efficacy of treatment. We delve into pivotal studies, including the Global Leader Study and the STOP-DAPT trial, that back these groundbreaking changes.Our conversation takes an intriguing turn as we explore the intersection of cardiology advancements with anesthesia practices. Discover how these developments are influencing preoperative settings, potentially altering surgical timing and decision-making in anesthesia care. We bring you exclusive insights from contributor, Janak Chandrasoma, featured in the October 2024 APSF newsletter. We urge you to explore further resources, share the knowledge with your peers, and join us in promoting patient safety in perioperative environments. Don't forget to rate, review, and share the episode with colleagues keen on staying at the forefront of anesthesia patient safety advancements.For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/229-revolutionizing-anesthesia-care-for-cardiac-patients/© 2024, The Anesthesia Patient Safety Foundation

Masahiro Natsuaki and C. Michael Gibson discuss this latest randomized comparison of prasugrel monotherapy and DAPT with aspirin for patients undergoing PCI.

New Season is starting off with our selection for the month and an exclusive mix from Y-DAPT!Your Monthly House Music Sandwich! In the mix every month with our favourite Electronic Dance Music releases + a guest mix from our DJs.  Disco Pastrami: Your Monthly Dance Music Sandwich!

Welcome to Season 6 of the Hot Topics podcast with Dr Neal Tucker. The summer holidays are over and it's back to work so time for a new podcast. In this episode, we look at research on whether SGLT2i might prevent dementia, on if it is safer to de-escalate sooner rather than later from dual anti-platelet therapy post-MI, and how effective is the new RSV vaccine at preventing hospitalisation in older people.ReferencesBMJ - SGLT2i & dementiaLancet - De-escalation of DAPT post-MIJAMA - RSV Vaccination Efficacy in Older Peoplewww.nbmedical.com/podcast

In the September 3, 2024, issue of JACC, Dr. Samuel Reinhart and team find that using direct oral anticoagulants alone is associated with fewer adverse events compared to combining them with aspirin after left atrial appendage occlusion. Their large-scale study suggests this streamlined approach might be optimal, though further randomized trials are needed to address limitations and refine long-term antithrombotic strategies.

This week, join Kate, Henry, Gary and Mark as they discuss same-day start contraception, krill oil for adults with knee DJD, misdiagnosis of community-acquired pneumonia, and ticagrelor + placebo VS ticagrelor + ASA after PCI. Plus some book recommendations: Whalefall, The Demon of Unrest, and the Commissario Brunetti novels by Donna Leon

Welcome back Rounds Table Listeners!We are back today with our Classic Rapid Fire Podcast!This week, Drs. Mike and John Fralick discuss two recent papers exploring the role of ticagrelor with aspirin versus ticagrelor alone after percutaneous coronary intervention in acute MI and the efficacy of empagliflozin after acute MI. Two papers, here we go!Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes (ULTIMATE-DAPT) (0:00 – 9:22). Empagliflozin after Acute Myocardial Infarction (9:22 – 16:00).And for the Good Stuff:Impact of presentation at conference with timed release of academic publication (16:00 – 17:32).Top spot in the PWHL and attendance record at stake in latest Montreal-Toronto showdown (17:32 – 19:59).Questions? Comments? Feedback? We'd love to hear from you! @roundstable

Rapha e Joanne conversam sobre dúvidas no manejo de pacientes com dengue: quando suspender DAPT? Quando suspender anticoagulantes? Quando internar por plaquetopenia? Quanto transfundir plaquetas? Devo usar coloide ou cristaloide? Referências: 1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde e Ambiente. Departamento de Doenças Transmissíveis. Dengue : diagnóstico e manejo clínico : adulto e criança [recurso eletrônico] / Ministério da Saúde, Secretaria de Vigilância em Saúde e Ambiente, Departamento de Doenças Transmissíveis.– 6. ed. – Brasília : Ministério da Saúde, 2024. 81 p.: il. Acesso: http://bvsms.saude.gov.br/bvs/publicacoes/dengue_diagnostico_manejo_clinico_6ed.pdf 2. Guidelines for the Clinical Diagnosis and Treatment of Dengue, Chikungunya, and Zika. Washington, D.C.: Pan American Health Organization; 2022. License: CC BY-NC-SA 3.0 IGO. https://doi.org/10.37774/9789275124871.

This week, Kate, Henry, Mark and Gary discuss antiplatelet medications to prevent dementia, post-stroke blood pressure control, the latest guideline for managing patients with chronic cardiac disease, and probiotics for patients with irritable bowel syndrome.

Special guest Dave L. Dixon, PharmD, FACC, FAHA, FCCP, FNLA, BCACP, CDCES, CLS, the Nancy L. and Ronald H. McFarlane Professor of Pharmacy and Chair of the Department of Pharmacotherapy & Outcomes Science at the Virginia Commonwealth University School of Pharmacy, joins us to talk about chronic coronary disease.Listen in as he discusses the management of chronic coronary disease with a focus on the new American College of Cardiology/American Heart Association guidelines.You'll also hear practical advice from panelists on TRC's Editorial Advisory Board:Anthony A. Donato, Jr., MD, MHPE, Associate Program Director, Tower Health System Internal Medicine Residency Program and Professor of Medicine at the Drexel University College of MedicineSteven E. Nissen, MD, MACC, the Chief Academic Officer at the Heart and Vascular Institute and the Lewis and Patricia Dickey Chair in Cardiovascular Medicine Professor of Medicine at the Cleveland Clinic Lerner School of Medicine at Case Western Reserve UniversityCraig D. Williams, PharmD, FNLA, BCPS, Clinical Professor of Pharmacy Practice at the Oregon Health and Science UniversityFor the purposes of disclosure, Dr. Dixon reports a relevant financial relationship [GLP-1 agonists, SGLT2 inhibitors] with Boehringer Ingelheim (grants/research support). Dr. Steven Nissen reports relevant financial relationships [cardiology] with AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Esperion, Medtronic, MyoKardia, New Amsterdam Pharma, Novartis, Pfizer, Silence Therapeutics (grants/research support).The other speakers have nothing to disclose. All relevant financial relationships have been mitigated.TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist's Letter or Prescriber's Letter account and look for the title of this podcast in the list of available CE courses.The clinical resources mentioned during the podcast are part of a subscription to Pharmacist's Letter and Prescriber's Letter: Toolbox: Optimizing Care of Patients with Coronary Artery DiseaseChart:  Dual Antiplatelet Therapy for Coronary Artery DiseaseChart:  Treatment of HypertensionIf you're not yet a Pharmacist's Letter or Prescriber's Letter subscriber, find out more about our product offerings at trchealthcare.com. Follow or subscribe, rate, and review this show in your favorite podcast app. You can also reach out to provide feedback or make suggestions by emailing us at ContactUs@trchealthcare.com.

ESC 2023: STOP-DAPT 3

Editor's Summary by Karen E. Lasser, MD, MPH, Senior Editor of JAMA, the Journal of the American Medical Association, for the June 27, 2023, issue. Related Content: Audio Highlights

The following question refers to Section 6.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by UCSD cardiology fellow Dr. Harpreet Bhatia, and then by expert faculty Dr. Jaideep Patel.Dr. Patel recently graduated from Virginia Commonwealth University cardiology fellowship and is now a preventive cardiologist at the Johns Hopkins Hospital.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #24 A 65-year-old man with a history of ischemic stroke 6 months ago presents to cardiology clinic to establish care. An event monitor was negative for atrial fibrillation and TTE with agitated saline study was negative for a patent foramen ovale. Therefore, his ischemic stroke was presumed to be non-cardioembolic in origin. He is currently taking lisinopril 5 mg daily for hypertension (BP in clinic is 115/70) and atorvastatin 40 mg daily. He has no history of significant gastrointestinal or other bleeding. What do you recommend next?AStart apixaban 5 mg BIDBIncrease lisinopril to 10 mg dailyCStart aspirin 81 mg dailyDStart aspirin 81 mg daily and clopidogrel 75 mg dailyEStart aspirin 81 mg daily and ticagrelor 90 mg BID Answer #24 ExplanationThe correct answer is C – start aspirin 81mg daily.For the secondary prevention of non-cardioembolic ischemic stroke or TIA, anti-platelet therapy is recommended with aspirin only (75-150 mg/day), dipyridamole + aspirin (slightly superior to aspirin), or clopidogrel alone (slightly superior to aspirin) (Class I, LOE A).DAPT with aspirin and clopidogrel or aspirin and ticagrelor should be considered in the immediate period after a minor ischemic stroke or TIA (3 weeks after event, Class IIa), but not 6 months after an ischemic stroke. Dual antiplatelet therapy with aspirin and clopidogrel increases bleeding risk without a significant benefit over either agent alone. Dual antiplatelet therapy with aspirin and ticagrelor increases bleeding risk, but does not improve disability incidence.Oral anticoagulation would be recommended for a cardioembolic stroke, which does not fit the clinical picture.His BP is well controlled so increasing lisinopril is not necessary.Main TakeawayFor the secondary prevention of an ischemic stroke or TIA, anti-platelet therapy with aspirin, aspirin + dipyridamole, or clopidogrel alone is recommended.Guideline Loc.6.3, page 3296-3297 CardioNerds Decipher the Guidelines - 2021 ESC Prevention SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor RollCardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

In this episode, host Dr. Sabeen Dhand speaks with neurosurgeons Drs. David Altschul and Omar Tanweer about updates on cerebral aneurysms, including device innovation, risk stratification, and the importance of the doctor-patient relationship in decision-making. --- CHECK OUT OUR SPONSOR MicroVention FRED X https://www.microvention.com/emea/product/fred-x --- SHOW NOTES Dr. Omar Tanweer is the director of cerebrovascular and endovascular neurosurgery at Baylor College of Medicine. He works in a multidisciplinary group of neurologists, radiologists, and neurosurgeons. He trained at NYU and has been at Baylor for 2 years, where he does 100% neurovascular work. Dr. David Altschul is also from New York and is the division chief of neurovascular surgery at Montefiore. He completed an endovascular fellowship in Manhattan and has now been back at Monteriore since 2014. Both physicians have an 80 to 20 endovascular to open case ratio. In the case of ruptured cerebral aneurysms, Dr. Altschul describes a rule of threes. Around one third of patients pass away before reaching a hospital, another third arrive with significant neurologic deficits, the final third simply endure a headache. The severity of symptoms on presentation is generally predictive of outcome. They use the Hunt and Hess score, as well as the Modified Fisher Scale in their workup. They will generally only put in a ventriculostomy if a patient is lethargic and has a Hunt and Hess grade of at least 3. Both physicians use viz.ai to review their aneurysm cases at their home institutions, as well as at all local referring hospitals, as they are all connected via the viz platform. For unruptured aneurysms, they implement the PHASES score and rely on patient preference. Some patients are comfortable monitoring the growth of very small aneurysms, while others prefer the risk of treating it over the risk of monitoring due to the fear of having a known aneurysm. The two agree that developing a good doctor-patient relationship is important in these cases, because getting to know your patient can help you decide which of these small aneurysms to treat. Finally, we discuss new technology in the treatment of cerebral aneurysms. Coils have improved by becoming smaller, containing biologic agents, and coming in different shapes. Dr. Tanweer discusses the difference between balloon and stent assisted techniques. Balloon assisted is great for wide neck aneurysms or patients who can't be on dual anti-platelet therapy (DAPT) and are better in the case of re-rupture. Stent assisted, when tolerated, increases efficacy and reduces recurrence by keeping coils in place, as well as providing a scaffold for endothelial cells to heal across. The Flow Diverter, a vessel preservation device, is less porous and good for internal carotid and anterior circulation aneurysms. The downside is that it requires DAPT. There is also the Web device, an intrasaccular device that diverts flow across the metal in the aneurysm and at the base of the neck, but does not leave any metal in the normal part of the artery. These are mainly used for wide neck bifurcation aneurysms at the internal carotid, basilar, anterior communicating, and middle cerebral artery bifurcations. --- RESOURCES Twitter: @DavidAltschulMD @omar_tanweer Viz.aneurysm: https://www.viz.ai/aneurysm

Merriam-Webster's Word of the Day for January 30, 2023 is: adapt • uh-DAPT • verb To adapt is to make or become fit (as for a new use) often by modification. // When people move to a new country, it can take them a while to adapt. // The teachers adapted the curriculum so that students of all abilities will benefit from it. See the entry > Examples: "Isaac Asimov's [Foundation] novels are collections of short stories and novellas spanning thousands of years, which makes them hard to adapt as a continuous story." — Belen Edwards, Mashable.com, 22 Dec. 2021 Did you know? "Nothing in this world is as reliable as change" is a common aphorism and one we can certainly attest to as lexicographers. English speakers adapted adapt, for example, in the 15th century from the Middle French adapter, which was itself an adaptation of Latin adaptāre. That source traces back to Latin aptus, meaning "fit" or "apt." Other adaptations of aptus in English include aptitude, inept, and of course apt itself, as well as unapt and inapt.

Annnnnnnnd We are back. Sorry, but after Andor has finally finished we have now got time to discuss the old type 1 MI, aka STEMI aka Occlusive Myocardial Infarction. Come listen for all those basics and some nuances around myocardial infarction in critically unwell patients. We talk when to DAPT, who gets full anticoagulation, hemodynamic support, and when to wake our Cardiology friends up in the night. 

CardioNerds (Amit and Dan) join Dr. Omid Amidi (CardioNerds Academy Graduate) and Dr. Marwah Shahid from the UCLA Cardiology Fellowship program along with Dr. Evelyn Song (CardioNerds Academy House Faculty and Heart Failure Hospitalist at UCSF) to discuss a complex case focused on management of severe coronary artery disease in a patient with Glanzmann thrombasthenia. Dr. Rushi Parikh (Interventional cardiologist, UCLA) provides the ECPR for this episode. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig. Glanzmann Thrombasthenia is a bleeding disorder due to impairment of platelet aggregation secondary to a mutation in the GPIIB/IIIA receptor. This case is focused on work up of stable coronary artery disease followed by a discussion on duration of dual antiplatelet therapy post percutaneous coronary intervention in a patient with Glanzmann thrombasthenia.   Check out this published case in JACC: Case Reports Jump to: Case media - Case teaching - References CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Case Media See the published case in JACC: Case Reports Episode Schematics & Teaching Pearls 1. Patients with Glanzmann thrombocytopenia (GT) may have a higher risk of bleeding, depending on their disease phenotype. 2. It is unclear whether the mechanism of GT protects patient against stent thrombosis in the setting of PCI. Additionally, there is little data on the use of antiplatelet agents in patients with GT. 3. Short-term DAPT may be a reasonably safe option for patients with GT undergoing PCI. 4. We report a successful case of percutaneous coronary intervention in a patient with GT with no complications at a 1 year follow up. Notes 1. What is Glanzmann thrombasthenia? GT is an inherited platelet disorder that is characterized by spontaneous bleeding with phenotypic variability ranging from minimal bruising to potentially fatal hemorrhaging.  GT is caused by autosomal recessive inheritance of quantitative or qualitative deficiencies of functional αIIbβ3 integrin coded by ITGA2B or ITGB3 genes for αIIb and β3, respectively. As a result, platelets may be stimulated, but the platelet glycoprotein IIb/IIIa receptor is unable to bind fibrinogen to cross-link platelets, rending them potentially ineffective. In platelet aggregation studies, there is lack of response to collagen, epinephrine, arachidonic acid, and ADP stimulation. Thus, platelet aggregation is impaired.  2. What is known about PCI and antiplatelet therapy in the setting of Glanzmann thrombasthenia? To the best of our knowledge, this is the first case report of percutaneous coronary intervention in the setting of GT. It is unclear if the mechanism of GT alone provides sufficient antiplatelet activity and whether antiplatelet therapy leads to significantly increased bleeding risk. The use of antiplatelet therapy is not well studied in the GT population. What we do know is that the mechanism of GT prevents platelet aggregation—the final step in platelet-related thrombosis—while oral antiplatelet therapy affects platelet activation, thus, in our patient we felt that short term DAPT was reasonable. It is important to note that in the event of an active bleed requiring platelet transfusion, donor platelets possess functional glycoprotein IIb/IIIa receptors and thus exponentially increase the risk of stent thrombosis. Therefore, unlike our case, if a patient is not maintained on chronic oral antiplatelet therapy, initiation of oral or intravenous antiplatelet therapy should be considered to prevent stent thrombosis at the time of platelet transfusion. Like any other patient with a high bleeding risk, it is important to have clear indications to conduct a coronary angiogram in patient...