Podcasts about Rivaroxaban

Today we do a round-up of some of the recent semaglutide trials. Does semaglutide ever miss? But what about tirzepatide, which causes even more weight loss?We also review two new critical care trials, FLUID and the UK-ROX, new platelet transfusion guidelines, and a new retrospective study of apixaban vs rivaroxaban vs warfarin. Oral Semaglutide for Diabetes with Cardiovascular Disease or CKD (SOUL)Semaglutide for Peripheral Artery Disease (STRIDE)Semaglutide for MASH (ESSENCE)Semaglutide vs Tirzepatide for Obesity (SURMOUNT-5)Normal Saline vs Lactated Ringers (FLUID)Conservative Oxygen Targets in Mechanically Ventilated Patients (UK-ROX)Platelet Transfusion GuidelinesApixaban vs Rivaroxaban vs Warfarin Music from Uppbeat (free for Creators!): https://uppbeat.io/t/soundroll/dope License code: NP8HLP5WKGKXFW2R

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances, discusses a recently published original research paper on A Comparison of Outcomes With Apixaban, Rivaroxaban, and Warfarin for Atrial Fibrillation and/or Venous Thromboembolism.

Marcela Belleza e Raphael Coelho convidam Matheus Rezende, residente do último ano de Cardiologia - Incor, para conversar sobre manejo de doença coronariana crônica em tres tópicos:- Como realizar a investigação inicial?- Como fazer a terapia medicamentosa inicial?- O que fazer com o paciente que não melhora?Referências: 1. Vrints C, Andreotti F, Koskinas KC, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes [published correction appears in Eur Heart J. 2025 Feb 21:ehaf079. doi: 10.1093/eurheartj/ehaf079.]. Eur Heart J. 2024;45(36):3415-3537. doi:10.1093/eurheartj/ehae1772. Virani, Salim S et al. “2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.” Circulation vol. 148,9 (2023): e9-e119. doi:10.1161/CIR.00000000000011683. Montone RA, Rinaldi R, Niccoli G, et al. Optimizing Management of Stable Angina: A Patient-Centered Approach Integrating Revascularization, Medical Therapy, and Lifestyle Interventions. J Am Coll Cardiol. 2024;84(8):744-760. doi:10.1016/j.jacc.2024.06.0154. Mortensen MB, Dzaye O, Steffensen FH, et al. Impact of Plaque Burden Versus Stenosis on Ischemic Events in Patients With Coronary Atherosclerosis. J Am Coll Cardiol. 2020;76(24):2803-2813. doi:10.1016/j.jacc.2020.10.0215. Doenst T, Haverich A, Serruys P, et al. PCI and CABG for Treating Stable Coronary Artery Disease: JACC Review Topic of the Week. J Am Coll Cardiol. 2019;73(8):964-976. doi:10.1016/j.jacc.2018.11.0536. Maron DJ, Hochman JS, Reynolds HR, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020;382(15):1395-1407. doi:10.1056/NEJMoa19159227. Rajkumar CA, Foley MJ, Ahmed-Jushuf F, et al. A Placebo-Controlled Trial of Percutaneous Coronary Intervention for Stable Angina. N Engl J Med. 2023;389(25):2319-2330. doi:10.1056/NEJMoa23106108. Eikelboom JW, Connolly SJ, Bosch J, et al. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med. 2017;377(14):1319-1330. doi:10.1056/NEJMoa17091189. Howlett JG, Stebbins A, Petrie MC, et al. CABG Improves Outcomes in Patients With Ischemic Cardiomyopathy: 10-Year Follow-Up of the STICH Trial. JACC Heart Fail. 2019;7(10):878-887. doi:10.1016/j.jchf.2019.04.01810. Nidorf SM, Fiolet ATL, Mosterd A, et al. Colchicine in Patients with Chronic Coronary Disease. N Engl J Med. 2020;383(19):1838-1847. doi:10.1056/NEJMoa202137211. Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-1516. doi:10.1056/NEJMoa07082912. Ford TJ, Stanley B, Good R, et al. Stratified Medical Therapy Using Invasive Coronary Function Testing in Angina: The CorMicA Trial. J Am Coll Cardiol. 2018;72(23 Pt A):2841-2855. doi:10.1016/j.jacc.2018.09.00613. Carvalho, Tales de et al. “Brazilian Cardiovascular Rehabilitation Guideline - 2020.” “Diretriz Brasileira de Reabilitação Cardiovascular – 2020.” Arquivos brasileiros de cardiologia vol. 114,5 (2020): 943-987. doi:10.36660/abc.20200407

For this episode we are joined by EBM guru, Dr. Brian Locke, who deftly breaks down all of our statistics questions. Is half dose DOAC as good as full dose DOAC for preventing VTE, and does it reduce bleeding risk? Can procalcitonin reduce duration of antibiotics for infections without compromising mortality rates? Can LLMs like GPT-4 help physicians manage patients better? Can reinforcement learning models predict when to start vasopressin in patients with septic shock? What is the risk of resuming anticoagulation in patients with atrial fibrillation and prior intracerebral hemorrhage? Is high flow nasal cannula as good as non-invasive ventilation for different types of respiratory failure? We answer all these questions and more!Half Dose DOAC for Long Term VTE Prevention (RENOVE)Biomarker-Guided Antibiotic Duration (ADAPT-Sepsis)GPT-4 Assistance for Physician PerformanceOptimal Vasopressin Initiation for Septic Shock (OVISS)DOACs for A fib after ICH (PRESTIGE-AF)High Flow Nasal Cannula vs NIV for Respiratory Failure (RENOVATE)Music from Uppbeat (free for Creators!): https://uppbeat.io/t/soundroll/dope License code: NP8HLP5WKGKXFW2R

  The RENOVE trial compared reduced-dose versus full-dose DOACs for extended venous thromboembolism VTE treatment in high-risk patients. While the reduced dose cut major bleeding risk by 39%

This week please join author Yugo Yamashita and Associate Editor Joshua Beckman as they discuss the article "Rivaroxaban for 18 Months Versus 6 Months in Patients With Cancer and Acute Low-Risk Pulmonary Embolism: An Open-Label, Multicenter, Randomized Clinical Trial (ONCO PE Trial)." For the episode transcript, visit: https://www.ahajournals.org/do/10.1161/podcast.20250303.648421

The AZALEA–TIMI 71 trial compared abelacimab, a monoclonal antibody targeting factor XI, with rivaroxaban in atrial fibrillation patients at moderate-to-high stroke risk.

We're back, after a brief hiatus! Today we talk about duration of therapy for bacteremia, Factor XI inhibition for atrial fibrillation, whether to stop ACEi or ARB before elective surgery, and whether GLP-1 agonists are beneficial in heart failure with preserved ejection fraction. Go to minute 7:30 to skip the banter. 7 vs 14 Days of Antibiotics for Bacteremia (BALANCE)Abelacimab vs Rivaroxaban for Atrial Fibrillation (AZALEA-TIMI-71)Asenduxian vs Apixaban for Atrial Fibrillation (OCEANIC-AF)ACEi or ARB Discontinuation Before Surgery (STOP or NOT)Tirzepatide for HFpEF and Obesity (SUMMIT)Music from Uppbeat (free for Creators!):https://uppbeat.io/t/soundroll/dopeLicense code: NP8HLP5WKGKXFW2R

In this episode of the Top 200 Drugs Podcast, we cover medications 126-130. Trastuzumab is a monoclonal antibody that can be used for breast cancer that expresses the HER2 protein. Atripla is an HIV medication that contains three separate medications that are beneficial in reducing viral load. Rivaroxaban is an anticoagulant that may be commonly used in the management of stroke and deep vein thrombosis. Fioricet is a combination of three medications. Butalbital, acetaminophen, and caffeine are the three ingredients in this medication. Insulin detemir is a long-acting insulin analog that lowers blood sugar. This medication is used to target fasting blood sugars.

A 67 year old woman with a history of hypertension, hyperlipidemia, diabetes, and a 25 pack year smoking history is referred your clinic and is referred for evaluation of her peripheral arterial disease. She reports pain with walking that has limited her doing some daily activities. How can you optimally manage this patient? Does she need an operation? In this episode, we will cover the basics of peripheral arterial disease, discuss the specifics of optimal medical management and dive into the nuances of when (or if) you should offer these patients an operation.  Hosts:  Dr. Bobby Beaulieu is an Assistant Professor of Vascular Surgery at the University of Michigan and the Program Director of the Integrated Vascular Surgery Residency Program as well as the Vascular Surgery Fellowship Program at the University of Michigan. Dr. Drew Braet is a PGY-5 Integrated Vascular Surgery Resident at the University of Michigan Learning Objectives - Review the definition, prevalence, and risk factors for peripheral arterial disease - Understand the specifics of optimal medical management of patients with peripheral arterial disease  - Discuss the controversy regarding operative management of patients with claudication and review indications for an operation in patients with peripheral arterial disease - Review the appropriate anti-platelet and anti-coagulation strategies after interventions in patients with peripheral arterial disease References 1.    Woo K, Siracuse JJ, Klingbeil K, Kraiss LW, Osborne NH, Singh N, Tan TW, Arya S, Banerjee S, Bonaca MP, Brothers T, Conte MS, Dawson DL, Erben Y, Lerner BM, Lin JC, Mills JL Sr, Mittleider D, Nair DG, O'Banion LA, Patterson RB, Scheidt MJ, Simons JP; Society for Vascular Surgery Appropriateness Committee. Society for Vascular Surgery appropriate use criteria for management of intermittent claudication. J Vasc Surg. 2022 Jul;76(1):3-22.e1. doi: 10.1016/j.jvs.2022.04.012. Epub 2022 Apr 22. PMID: 35470016. https://pubmed.ncbi.nlm.nih.gov/35470016/ 2.    Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W; ESVS Guidelines Committee; Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A; Document Reviewers; Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg. 2024 Jan;67(1):9-96. doi: 10.1016/j.ejvs.2023.08.067. Epub 2023 Nov 10. PMID: 37949800. https://pubmed.ncbi.nlm.nih.gov/37949800/ 3.    Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024 Jun 11;149(24):e1313-e1410. doi: 10.1161/CIR.0000000000001251. Epub 2024 May 14. PMID: 38743805. https://pubmed.ncbi.nlm.nih.gov/38743805/ 4.    Belch JJ, Dormandy J; CASPAR Writing Committee; Biasi GM, Cairols M, Diehm C, Eikelboom B, Golledge J, Jawien A, Lepäntalo M, Norgren L, Hiatt WR, Becquemin JP, Bergqvist D, Clement D, Baumgartner I, Minar E, Stonebridge P, Vermassen F, Matyas L, Leizorovicz A. Results of the randomized, placebo-controlled clopidogrel and acetylsalicylic acid in bypass surgery for peripheral arterial disease (CASPAR) trial. J Vasc Surg. 2010 Oct;52(4):825-33, 833.e1-2. doi: 10.1016/j.jvs.2010.04.027. Epub 2010 Aug 1. Erratum in: J Vasc Surg. 2011 Feb;53(2):564. Biasi, B M [corrected to Biasi, G M]. PMID: 20678878. https://pubmed.ncbi.nlm.nih.gov/20678878/ 5.    Eikelboom JW, Connolly SJ, Bosch J, Dagenais GR, Hart RG, Shestakovska O, Diaz R, Alings M, Lonn EM, Anand SS, Widimsky P, Hori M, Avezum A, Piegas LS, Branch KRH, Probstfield J, Bhatt DL, Zhu J, Liang Y, Maggioni AP, Lopez-Jaramillo P, O'Donnell M, Kakkar AK, Fox KAA, Parkhomenko AN, Ertl G, Störk S, Keltai M, Ryden L, Pogosova N, Dans AL, Lanas F, Commerford PJ, Torp-Pedersen C, Guzik TJ, Verhamme PB, Vinereanu D, Kim JH, Tonkin AM, Lewis BS, Felix C, Yusoff K, Steg PG, Metsarinne KP, Cook Bruns N, Misselwitz F, Chen E, Leong D, Yusuf S; COMPASS Investigators. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med. 2017 Oct 5;377(14):1319-1330. doi: 10.1056/NEJMoa1709118. Epub 2017 Aug 27. PMID: 28844192. https://pubmed.ncbi.nlm.nih.gov/28844192/ 6.    Bonaca MP, Bauersachs RM, Anand SS, Debus ES, Nehler MR, Patel MR, Fanelli F, Capell WH, Diao L, Jaeger N, Hess CN, Pap AF, Kittelson JM, Gudz I, Mátyás L, Krievins DK, Diaz R, Brodmann M, Muehlhofer E, Haskell LP, Berkowitz SD, Hiatt WR. Rivaroxaban in Peripheral Artery Disease after Revascularization. N Engl J Med. 2020 May 21;382(21):1994-2004. doi: 10.1056/NEJMoa2000052. Epub 2020 Mar 28. PMID: 32222135. https://pubmed.ncbi.nlm.nih.gov/32222135/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

It's been a long time, but we are back!Apologies on the audio quality from Dr. Jenkins. Apparently he was recording from inside a cardboard box.Today we talk about important, practice changing studies in internal medicine from the last several months. What's the best anticoagulant in patients with cirrhosis and atrial fibrillation? Why do doctors use so much unfractionated heparin for acute PE? Should we still be using beta blockers in patients with acute MI? Does finerenone improve outcomes in HFpEF? Is continuous infusion of antibiotics better than intermittent? And will the cefepime vs piperacillin-tazobactam battle ever end?Apixaban, Rivaroxaban and Warfarin in Cirrhosis for AFAnticoagulation Trends for Acute PEBeta Blockers for Acute MI with Normal EF Finerenone for HFpEF FINEARTS-HFContinuous vs Intermittent Infusion of Beta-Lactams BLING IIIProlonged vs Intermittent Infusions of Beta-Lactams Meta-analysisPiperacillin-Tazobactam vs Cefepime for SepsisRecurrent SBP in Patients on Secondary Prophylaxis

Pedro Magno e Kaue Malpighi falam sobre o passo a passo da prescrição de rivaroxabana e apixabana: quando indicar? o que orientar o paciente? qual dose tomar? Tudo nesse episódio! No Guia TdC comentamos sobre como reverter o sangramento associado aos DOACs. Você pode ler esse tópico gratuitamente, basta clicar no link abaixo e fazer o login: Manejo de Sangramento Maior em Pacientes em Uso de Anticoagulante Oral | Guia TdC (tadeclinicagem.com.br) Referência: Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543-603. doi:10.1093/eurheartj/ehz405 Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) [published correction appears in Eur Heart J. 2021 Feb 1;42(5):507. doi: 10.1093/eurheartj/ehaa798] Siontis KC, Zhang X, Eckard A, et al. Outcomes Associated With Apixaban Use in Patients With End-Stage Kidney Disease and Atrial Fibrillation in the United States [published correction appears in Circulation. 2018 Oct 9;138(15):e425. doi: 10.1161/CIR.0000000000000620]. Circulation. 2018;138(15):1519-1529. doi:10.1161/CIRCULATIONAHA.118.035418 Holt A, Strange JE, Rasmussen PV, et al. Bleeding Risk Following Systemic Fluconazole or Topical Azoles in Patients with Atrial Fibrillation on Apixaban, Rivaroxaban, or Dabigatran. Am J Med. 2022;135(5):595-602.e5. doi:10.1016/j.amjmed.2021.11.008 Beyer-Westendorf J, Siegert G. Of men and meals. J Thromb Haemost. 2015;13(6):943-945. doi:10.1111/jth.12973

Dr. Valentin Fuster discusses a study on the effects of low-dose rivaroxaban combined with aspirin in fragile patients after lower extremity revascularization, focusing on the balance between efficacy and safety. It highlights that while frailty increases the risk of adverse outcomes, rivaroxaban reduces ischemic events but also raises bleeding risks, regardless of frailty status. The editorial emphasizes that frailty should not preclude the use of combined antithrombotic therapy, advocating for personalized treatment approaches.

N Engl J Med 2012;366:9-19Background Following an acute coronary syndrome, individuals have a substantially elevated risk of recurrent events, compared to a similar individual who did not experience ACS, despite the use of appropriate risk reducing therapies. This is termed “residual risk” and the concept has been mentioned in prior reviews. The quest to lower residual risk continues to be a major driver of new products and therapeutic concepts in cardiovascular medicine.Rivaroxaban is an oral anticoagulant that directly and selectively inhibits factor Xa. Factor Xa initiates the final common pathway of the coagulation cascade resulting in the formation of thrombin. Thrombin promotes platelet aggregation. At the time the trial was undertaken, both aspirin and thienopyridines were established agents that worked via different mechanisms, downstream of thrombin formation, to stop platelets from sticking together. Could the addition of an agent that inhibits thrombin formation, upstream of platelet activation and aggregation, reduce risk further without causing a prohibitive increase in bleeding risk?A meta-analysis of small trials involving the use of warfarin, in addition to aspirin, suggested that warfarin, an indirect inhibitor of thrombin, could improve cardiovascular outcomes. And a phase 2 dose finding trial with rivaroxaban provided further support. Thus, the ATLAS ACS-TIMI 51 trial sought to test the hypothesis that adding rivaroxaban to standard therapies, at 2.5 or 5 mg twice daily, would reduce cardiovascular events compared to placebo.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Patients Adults who had presented with an acute coronary syndrome (STEMI, NSTEMI or unstable angina). Patients under 55 years of age had to have either diabetes or a history of a previous MI. Patients were excluded if they had a platelet count

Commentary by Dr. Candice Silversides

Welcome to the latest episode of Cardiology Digest, where we dive into the pressing questions of today's medical research. Here's a glimpse of what's to come:   STUDY #1: Have you ever wondered about the optimal timing for introducing DOACs (direct-acting oral anticoagulants) after strokes due to atrial fibrillation? This New England Journal of Medicine study dives into the potential advantages of early DOAC introduction. You might be surprised at the rates of symptomatic intracranial hemorrhage. But remember, patient profiles vary—for example, what works for those with mild neurologic deficits might not hold true for everyone. Fischer, U, Koga, M, Strbian, D, et al. 2023. Early versus later anticoagulation for stroke with atrial fibrillation. N Engl J Med. 26: 2411–2421. (https://doi.org/10.1056/NEJMoa2303048)   STUDY #2: Next, we'll take a look at the curious case of rising hematocrit in certain chronic kidney disease patients who have anemia and were treated with SGLT-2 inhibitors. Did they have a genuine improvement in anemia or was it merely an illusion? SGLT-2 inhibitors are the focal point, and we'll dissect their multifaceted effects that may be at play here.  Koshino, A, Schechter, M, Chertow, GM, et al. 2023. Dapagliflozin and anemia in patients with chronic kidney disease. NEJM Evid.  6. (https://doi.org/10.1056/EVIDoa2300049)   STUDY #3: Hospitalization due to COVID-19 has presented a conundrum regarding post-discharge thromboprophylaxis. With the pandemic making such profound impacts on global health, it's crucial to address these concerns. See how new findings align with prior observational studies, and where rivaroxaban fits into all of this. Wang, TY,  Wahed, AS, Morris, A, et al. 2023. Effect of thromboprophylaxis on clinical outcomes after COVID-19 hospitalization. Ann Intern Med. 4: 515–523. (https://doi.org/10.7326/M22-3350)   STUDY #4: Cholesterol management remains pivotal in cardiac care. But the question our fourth study poses is this: do age differences impact the effectiveness of statins, particularly in lowering LDL cholesterol? A dive into this study could reshape perceptions on dosage recommendations for certain patient demographics. Corn, G, Melbye, M, Hlatky, MA, et al. 2023. Association between age and low-density lipoprotein cholesterol response to statins: A Danish nationwide cohort study. Ann Intern Med. 8: 1017–1026. (https://doi.org/10.7326/M22-2643)   So, arm yourself with your favorite beverage and comfy earphones, and join us in uncovering the gems these studies hold. The revelations might just change the way you see these medications and treatments!

On Episode 34 of the Stroke Alert Podcast, host Dr. Negar Asdaghi highlights two articles from the November 2023 issue of Stroke: “Identification of Clinically Relevant Brain Endothelial Cell Biomarkers in Plasma” and “Robot-Assisted Transcranial Doppler Versus Transthoracic Echocardiography for Right to Left Shunt Detection.” She also interviews Dr. Thalia Field about her article “Study of Rivaroxaban for Cerebral Venous Thrombosis: A Randomized Controlled Feasibility Trial Comparing Anticoagulation With Rivaroxaban to Standard-of-Care in Symptomatic Cerebral Venous Thrombosis.” For the episode transcript, visit: https://www.ahajournals.org/do/10.1161/podcast.20231027.572752

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021.Originally released: December 5, 2019In 2016, when we first launched the BrainWaves podcast, cryptogenic stroke was a poorly understood concept. Three years later, it remains poorly understood. But we are making progress. In this week's update of episode 10, we review the progress that has been made in the pathogenesis, diagnosis, and management of these patients.Produced by James E Siegler. The original 2016 version of this show was also produced by Dr. Noah Levinson. Music courtesy of Josh Woodward, Julie Maxwell, Dan Lebowitz, and this group called E's Jammy Jams. Sound effects by Mike Koenig and Daniel Simion. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision-making. Be sure to follow us on Twitter @BrainWavesaudio for the latest updates to the podcast.REFERENCESDi Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S. Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med 1992;117(6):461-5. PMID 1503349Diener HC, Sacco RL, Easton JD, et al. Dabigatran for prevention of stroke after embolic stroke of undetermined source. N Engl J Med 2019;380(20):1906-17. PMID 31091372Fonseca AC, Ferro JM. Drug abuse and stroke. Curr Neurol Neurosci Rep 2013;13(2):325. PMID 23299821Hart RG, Sharma M, Mundl H, et al. Rivaroxaban for stroke prevention after embolic stroke of undetermined source. N Engl J Med 2018;378(23):2191-201. PMID 29766772Jacobs BS, Boden-Albala B, Lin IF, Sacco RL. Stroke in the young in the northern Manhattan stroke study. Stroke 2002;33(12):2789-93. PMID 12468771Juul K, Tybjaerg-Hansen A, Steffensen R, Kofoed S, Jensen G, Nordestgaard BG. Factor V Leiden: The Copenhagen City Heart Study and 2 meta-analyses. Blood 2002;100(1):3-10. PMID 12070000Kaku DA, Lowenstein DH. Emergence of recreational drug abuse as a major risk factor for stroke in young adults. Ann Intern Med 1990;113(11):821-7. PMID 2240897Li J, Liu J, Liu M, et al. Closure versus medical therapy for preventing recurrent stroke in patients with patent foramen ovale and a history of cryptogenic stroke or transient ischemic attack. Cochrane Database Syst Rev 2015;2015(9):CD009938. PMID 26346232Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017;377(11):1011-21. PMID 28902593Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000;55(8):1172-9. PMID 11071496Perera KS, Ng KK, Nayar S, et al. Association between low-dose rivaroxaban with or without aspirin and ischemic stroke subtypes: a secondary analysis of the COMPASS Trial. JAMA Neurol 2020;77(1):43-8. PMID 31524941Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical thera

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: July 18, 2017 Long-term antithrombotic treatment of embolic stroke sounds like a tricky field to navigate. Aspirin is the drug of choice in the acute setting for most patients, but when cardioembolic stroke is suspected, aspirin is inferior to anticoagulation for preventing recurrent stroke. In the age of novel oral anticoagulants, why choose warfarin and risk drug interactions, dietary restrictions, and bleeding risk? In this episode, we discuss the pros and cons of each of the major NOACs for secondary stroke prevention. Enjoy! BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision-making in routine clinical practice. Any cases discussed in this episode are fictional and do not contain any patient health-identifying information. REFERENCES Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361(12):1139-51. Erratum in: N Engl J Med 2010;363(19):1877. PMID 19717844Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013;369(22):2093-104. PMID 24251359Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365(11):981-92. PMID 21870978Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365(10):883-91. PMID 21830957 We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date.

Coronary calcium, cardiac arrest survival, Factor XI drug findings, APCs and a potential new board certification in cardiology 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 Coronary Artery Calcium -   CONFIRM Registry - https://doi.org/10.1016/j.jcmg.2023.03.008 -   CURE -- https://www.nejm.org/doi/full/10.1056/nejmoa010746 II Cardiac Arrest Cardiac Arrest Centers No Benefit in OHCA Without STEMI https://www.medscape.com/viewarticle/995885 -   Cycling coverage https://velo.outsideonline.com/road/road-racing/nathan-van-hooydonck-forced-to-end-to-racing-career-due-to-heart-condition/ -   ARREST https://doi.org/10.1016/S0140-6736(23)01351-X -   SCD in Athletes Bob Harrington and Manesh Patel https://www.medscape.com/viewarticle/995575 III Factor XI Trial Halted for Bleeding Reduction With Abelacimab vs Rivaroxaban in AF https://www.medscape.com/viewarticle/996587 -   Press Release - https://anthostherapeutics.com/wp-content/uploads/2023/09/2023-09-18-Anthos-Press-Release-final.pdf -   Abelacimab, a Factor XI Inhibitor, Prevents VTE With Low Bleeding Risk in Knee Replacement -   NEJM proof-of-concept https://www.nejm.org/doi/full/10.1056/NEJMoa2105872 -   OCEANIC-AF https://classic.clinicaltrials.gov/ct2/show/NCT05643573 -   Will Factor XI Be the Goldilocks Anticoagulant Target? https://www.medscape.com/viewarticle/979634 IV APC Care NPs and PAs Handling Increasingly More Primary Care Visits: New Studies https://www.medscape.com/viewarticle/996709 BMJ paper -- https://www.bmj.com/content/382/bmj-2022-073933 V Possible Cardiology Board Certification Changes -   Heart Societies Ready to Split From ABIM Over MOC Disputes https://www.medscape.com/viewarticle/996747 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Show notes at pharmacyjoe.com/episode830. In this episode, I'll discuss using heparin anti-Xa levels to evaluate apixaban, rivaroxaban, fondaparinux, and danaparoid levels. The post 830: Using Heparin Anti-Xa Levels to Evaluate Apixaban, Rivaroxaban, Fondaparinux, or Danaparoid Levels appeared first on Pharmacy Joe.

Show notes at pharmacyjoe.com/episode830. In this episode, I ll discuss using heparin anti-Xa levels to evaluate apixaban, rivaroxaban, fondaparinux, and danaparoid levels. The post 830: Using Heparin Anti-Xa Levels to Evaluate Apixaban, Rivaroxaban, Fondaparinux, or Danaparoid Levels appeared first on Pharmacy Joe.

Commentary by Dr. Stephanie Carlin

Every year, nearly 800,000 people in the United States have a stroke. Listen in to a Stroke Coordinator on how his role helps to save lives, transform patient care, and reduce costs. Episode Introduction  Monte explains why data abstraction is the biggest part of a stroke coordinator's role, the importance of maintaining patient focus and why ‘'responsibility without authority'' means teamwork and communication are vital. He also highlights his unique position in understanding the time sensitive nature of treating stroke patients, and how patient arrival time dropped by 100 minutes following a community awareness campaign.   Show Topics   Data abstraction is the biggest factor for a stroke coordinator  Ensuring patient follow-up for better patient care Making a difference as a stroke coordinator The ads that transformed patient education Why teamwork and communication is a must  The cost savings benefits of hiring a stroke coordinator Leadership is about helping others to succeed     07:47 Data abstraction is the biggest factor for a stroke coordinator Monte explained the ‘'life-changing'' impact of data abstraction on his role and ability to improve patient care.  ‘'The largest part of being a stroke coordinator is data abstraction. There is tons of data abstraction. It's incredibly time-consuming. There's information that I have to gather on every single patient that arrives with stroke-like symptoms. That is probably two to three times the amount of patients that actually become stroke patients. So it's a huge number of patients. So every code stroke in the hospital, which sometimes there's two, three, four a day, those are patients that I have to do data abstraction on. Then I also have to understand how the data determines opportunities for improvement, and that was something I was so completely unaware of as a regular nurse. I was just working in the hospital. Data seemed, it used to make me angry when someone would come at me with data because I'm like, "I don't care about your data. All I care about is the patient. So then I learned that data actually drives this change, and so I learned how data drives the change, and it's been really, really fascinating and very life-changing for me and being able to look at things and say, "Oh, here's where we can make improvements for these patients."   11:15 Ensuring patient follow-up for better patient care Monte said that arranging neurology appointments for all stroke and TIA patients was another key element of the stroke coordinator's role. ‘'Right now we're providing neurology appointments for all of our stroke and TIA patients. So I spend a lot of time going back and forth with their office to create those appointments and tracking those. There's just tons of tracking of everything. …..that's something …. that we just started doing this last year. We just started doing the TIA patients first, and then we added all the stroke patients in. So that way they have follow up outside of the hospital once they go home. Because a lot of people went home and they didn't follow up with someone and we found that if we create their appointment for them before they leave or even shortly after they leave, then they're more likely to go to the appointment.''   12:44 Making a difference as a stroke coordinator Monte said the stroke coordinator is vital for stroke centers to receive certification and in ensuring rapid treatment of patients.  ‘'Well, number one, the easiest one to tell you is to be a designated stroke receiving center by the county. We have to be a stroke certified hospital, so we can't lose that certification. So in other words, in order to be that receiving center, what a designated receiving center is? Well, when someone picks up the phone and calls 911 and the patient has stroke-like symptoms, they immediately go to our hospital if it's the closest hospital to them because we are the stroke center. Now in Monterey, two of them, and one is on the west side of the county, one's on the east side, we're on the east side, and we don't fight over patients. There's no argument or anything. It's just split right down the middle. And so if they're on the east side, they come to us. If they're on the west side, they go to them. But that is one of the biggest things, is if we didn't have that designation, we would lose a lot of patients to another stroke center. And the other thing is for cardiac, we always heard time is muscle, the second is true for stroke, time is brain. And people don't realize that approximately 1.9 million neurons die every minute during a large vessel occlusion. So we are racing, when they first come in, we are racing to give them treatment to dissolve that clot or whatever else so that we can restore that blood flow back to that area of the brain, because the longer they go without that blood flow, the more brain damage they're going to have. So that is what the whole thing is when they first come in.''   14:10 The ads that transformed patient education  Monte said the average time for patients arriving at hospital after a stroke dropped by 100 minutes through raising awareness.  ‘'And the other thing where we make a huge difference in the community is because stroke is very time sensitive as far as treatment is concerned, you communicate and teach the community about stroke, stroke symptoms and recognizing those and getting into the hospital as quickly as possible.  My partner, who is the cardiovascular coordinator, he and I have gone back and forth. We've gone to so many community events and everything trying to make a difference, and nothing has really made a difference. All of a sudden one day he said to me, "Why don't we advertise on the side of buses and advertise in the theater?" …… So this is where data comes in handy. If it makes a difference, we're looking at the time someone recognizes their symptom to the time they arrive at the hospital. If it makes a difference, it should be shorter. We did that and it was fascinating. We only ran the ads for three months and we could see that time. The average time dropped almost 100 minutes over those three months, and then after the ads stopped, they slowly started coming back up again. So the next year we thought, okay, this is maybe a fluke. Let's do it at a different time of year, whatever. This time we both did the ads because the bus ads did nothing. We ran both of our ads in the theater, same thing happened within a short time. Those times dropped down over 100 minutes this time. So now we advertise in the theater year round. And we started that and then all of a sudden COVID hit, which was funny, and all the theaters closed. So we had to wait until they opened up again to redo that. But it makes a huge difference to our patient population.''    17:52 Why teamwork and communication is essential   Monte said stroke coordinators have a lot of responsibility but no authority, making communication and teamwork essential.  ‘'So for instance, I want to make a change or something. Any change that I make, it will require someone else or some other department in order to make that change. So if I make a change in the code stroke process, for instance, it's going to affect the ER physicians, the ER nurses, the lab techs, CT techs and EMS. All of those people and all of them have to be involved in that change. So you really create buy-in and get people to understand why we're making this change and why it's so important. So for instance, we brought the MEND exam, which is a stroke neurological exam. You to go back, be educated in Miami and have four other people be educated as well, and then bring the class to our hospital and start teaching that class in the hospital. But in order to get our nurses to actually learn the MEND exam, we had to release a health stream for everyone to do it because we couldn't require that advanced stroke life support be taught to them, which teaches the MEND exam, because the union. So if we want to make it mandatory for say, the stroke unit or ER or ICU, we have to go to the union and have that negotiated into the contract for those things. So these are the things that requires a lot of time communication and working with every single person involved. Right now we're bringing in new drugs. We're bringing in ANDEXXA, which is a reversal agent for apixaban and Rivaroxaban. That included our physicians, our nurses, our clinical informatics to write the order sets. And coming up, we're going to be bringing connect to place in. So we're going to have to go through the same thing again. So each one of those things requires communication, buy-in from all these departments and everybody being on board. And if I don't have that, it's not going to happen.''   21:04 The cost savings benefits of hiring a stroke coordinator Monte highlighted the best practices of stroke coordinators that enhance patient care, while saving money.  ‘'Well, first of all, being a stroke designated center by the county brings those patients there. So that immediately brings patients that we wouldn't normally receive. But how we help our patients is, for instance, we know that and studies have shown that for every 15 minutes we can shave off of the time that symptoms have started to the time they get treatment, the patient is that much more likely to walk out of the hospital as opposed to going to a skilled nursing facility or rehab event. That is why we put this money into our theaters to bring patients in sooner, because the sooner they get there, the more like they're going to be walk out instead of go to one of these places. That also decreases their length of stay, which it lowers their cost as well as our cost. So each one of these things that we do, we bring best practice to the hospital for stroke, which actually improves our performance. It improves best patient practice and best patient experience.''   27:34 Leadership is about helping others to succeed Monte said that transparency and honesty can make a big difference to others.  ‘' I always go back to what I looked at in a leader, and that was someone who was direct, someone who honest, someone who was transparent and someone who just came from a place of love, everything that they do in all of their management style. Those people always made the biggest difference in me. So that's the person I want to be, and I know I'm not always that. Many times I'm not, but that's the person that I want to be and that's what I want to learn. And so I'm constantly striving to do that. And I highly suggest if you are going to go into leadership that you begin to understand that if you make everyone else around you succeed, you are a huge success.''   Connect with Lisa Miller on LinkedIn Connect with Jim Cagliostro on LinkedIn Connect with Monte MoosJenkins on LinkedIn   Check out VIE Healthcare and SpendMend      You'll also hear:  From nursing burnout to stroke coordinator, via teaching and travel nursing, and lessons learned as a branch manager. ‘'I am a Libra, so I tend to be a doormat, and I was a doormat up to that time. And it really taught me that if I'm going to let something go on instead of dealing with it directly and immediately, it's going to come back and bite me in the butt. And that was a really, really good lesson for me and I've learned to be very direct from that.'' The importance of patient focus. ‘'As long as you keep the patient in focus and everything you're doing for the patient is about the patient and everything you do at work is about the patient, then no one can fault you for that. You just need to keep the patient always at the forefront.'' Why education matters in the role of stroke coordinator. ''The interesting thing about being a stroke coordinator, I'm responsible for always updating the knowledge on stroke guidelines for the hospital, any changes in stroke care, all that kind of stuff.. … I have to make sure that education takes place for all of those things.'' How a mentor helped Monte to listen rather than react ‘'… I think that's why a mentor is so, so important because they can look at you and say, "Calm down. I know you're upset about this and I understand why you're upset about this, but that's not going to do anybody any good."   What To Do Next:   Subscribe to The Economics of Healthcare and receive a special report on 15 Effective Cost Savings Strategies.   There are three ways to work with VIE Healthcare:   Benchmark a vendor contract – either an existing contract or a new agreement. We can support your team with their cost savings initiatives to add resources and expertise. We set a bold cost savings goal and work together to achieve it.  VIE can perform a cost savings opportunity assessment. We dig deep into all of your spend and uncover unique areas of cost savings.  If you are interested in learning more, the quickest way to get your questions answered is to speak with Lisa Miller at lmiller@spendmend.com or directly at 732-319-5700  

CME credits: 1.25 Valid until: 27-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/consistent-benefit-of-rivaroxaban-early-and-late-after-lower-extremity-revascularization/15287/ In this program, expert faculty discuss data presented at the 2023 ACC Congress in a concise, informative, on-demand format. This format extends the congress analysis to a broader audience with greater detail than what is available in abstracts. Rapid advances from the meeting require well-planned educational programming to bridge knowledge, competence, and performance gaps.

In this episode, we will discuss all things peripheral arterial disease – definitions, staging, clinical presentation, risk factors, goals of therapy, and guideline-directed medication therapy recommendations including the newest evidence for the use of DOACs. Key Concepts Addressing modifiable risk factors (weight loss, smoking cessation, blood pressure and blood glucose control, dyslipidemia, structured exercise program, etc.) are recommended for the treatment of PAD. Single antiplatelet therapy with either aspirin 81 mg or clopidogrel 75 mg daily are recommended in patients to reduce stroke, MI and other vascular deaths in symptomatic (1A) and asymptomatic patients (IIa- C-EO). Rivaroxaban 2.5 mg BID, when added to aspirin 81 mg daily, is superior to aspirin alone in preventing composite outcome of stroke, MI, and CV death in PAD patients with recent revascularization surgery for PAD but increases the risk of major bleeding. In the absence of heart failure, cilostazol is effective in improving symptoms, quality of life, and increasing walking distance in patients with intermittent claudication.  References Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e686–e725. https://doi.org/10.1161/CIR.0000000000000470 Criqui MH, Matsushita K, Aboyans V, et al. Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association. Circulation. 2021;144:e171–e191. https://doi.org/10.1161/CIR.0000000000001005 Alonso-Coello P, Bellmunt S, McGorrian C, Anand SS, Guzman R, Criqui MH, Akl EA, Vandvik PO, Lansberg MG, Guyatt GH, Spencer FA. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e669S-e690S. doi: 10.1378/chest.11-2307. PMID: 22315275; PMCID: PMC3278062. Eikelboom JW, Connolly SJ, Bosch J, et al. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med. 2017; 377:1319-1330. https://www.nejm.org/doi/full/10.1056/nejmoa1709118 Bonaca MP, Bauersachs RM, Anand SS, et al. Rivaroxaban in peripheral arterial disease after revascularization. N Engl J Med. 2020; 382:1994-2004. https://www.nejm.org/doi/full/10.1056/nejmoa2000052

Commentary by Dr Xianbao Liu

FDA Panel votes on the potential removal from the market of Makena; results from an apixaban trial of patients with atrial fibrillation and valvular heart disease; reports of serious ocular complications with monkeypox infection; the novavax vaccine becomes the latest authorized COVID-19 booster; and treatments for nephropathy and ALS have their review period extended.

C. Michael Gibson and Renato Lopes discuss extended DOAC prophylaxis in medically ill, hospitalized patients with COVID-19.

Show notes at pharmacyjoe.com/episode757. In this episode, I'll discuss an article about the reversal of apixaban and rivaroxaban with andexanet alfa prior to invasive or surgical procedures. The post 757: Reversal of Apixaban and Rivaroxaban with Andexanet Alfa Prior to Invasive or Surgical Procedures appeared first on Pharmacy Joe.

Show notes at pharmacyjoe.com/episode757. In this episode, I ll discuss an article about the reversal of apixaban and rivaroxaban with andexanet alfa prior to invasive or surgical procedures. The post 757: Reversal of Apixaban and Rivaroxaban with Andexanet Alfa Prior to Invasive or Surgical Procedures appeared first on Pharmacy Joe.

Back by popular demand, Dr Ankur Kalra's guest is Dr Purvi Parwani, Director of Women's Cardiovascular Disease Clinic and Assistant Professor at Loma Linda University Medical Center, US. In this ESC 2022 edition of Parallax, Ankur asks Purvi to review her highlights of the congress. Purvi details the study design and key findings of each trial and provides her insights after attending the event in Barcelona. Ankur and Purvi discuss how each trial will inform their practice. Trials covered in detail include: - REVIVED: Study of Efficacy and Safety of Percutaneous Coronary Intervention to Improve Survival in Heart Failure (NCT01920048) - DANCAVAS: Danish Cardiovascular Screening Trial II (NCT03946410) - DELIVER: Dapagliflozin Evaluation to Improve the LIVEs of Patients With PReserved Ejection Fraction Heart Failure (NCT03619213) - SECURE: Secondary Prevention of Cardiovascular Disease in the Elderly Trial (NCT02596126) - INVICTUS: INVestIgation of rheumatiC AF Treatment Using Vitamin K Antagonists, Rivaroxaban or Aspirin Studies, Non-Inferiority (NCT02832544) What are the key take-home messages of ESC 22? How can we implement these findings into daily practice? Where are the opportunities for further research? Questions and comments can be sent to “podcast@radcliffe-group.com” and may be answered by Ankur in the next episode. Guest: @purviparwani, host: @AnkurKalraMD and produced by: @RadcliffeCARDIO.

This week on Pharm5: Terlivaz (terlipressin) for hepatorenal syndrome Pfizer's mRNA flu vaccine (enroll here: https://bit.ly/3DMRO0r) Potential triple-action drug for diabetes or weight loss Warfarin use in AFib with rheumatic heart disease CVS and Walmart settle; Walgreens heads to court References Terlivaz. Package Insert. Mallinckrodt Pharmaceuticals; 2022. Pharmacypracticenews.com. https://bit.ly/3xHxgTm. Published September 15, 2022. Accessed September 22, 2022. Biggins SW, Angeli P, Garcia‐Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and Hepatorenal Syndrome: 2021 practice guidance by the American Association for the study of liver diseases. Hepatology. 2021;74(2):1014-1048. doi:10.1002/hep.31884 Pfizer initiates phase 3 study of mrna-based influenza vaccine. Pfizer. https://bit.ly/3dBgvCx. Published September 14, 2022. Accessed September 22, 2022. Mitchel L. Zoler PD. Triple threat: Novel agent shows potent T2D Weight Loss. Medscape. https://wb.md/3SmPWzK. Published September 22, 2022. Accessed September 22, 2022. A1C and weight change results: Mounjaro™ (tirzepatide). Mounjaro. https://bit.ly/3DNdutI. Accessed September 22, 2022. Connolly SJ, Karthikeyan G, Ntsekhe M, et al. Rivaroxaban in rheumatic heart disease–associated atrial fibrillation. New England Journal of Medicine. 2022;387(11):978-988. doi:10.1056/nejmoa2209051 Knauth D. CVS, Walmart reach $147.5 million opioid settlement with West Virginia. Medscape. https://wb.md/3BGNWeK. Published September 22, 2022. Accessed September 22, 2022.

A second ESC review covering REVIVED, the DANCAVAS CV screening trial, DELIVER on dapagliflozin in HF with mildly reduced EF, and the INVICTUS trial of rivaroxaban in rheumatic heart disease. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I REVIVED BCIS - PCI Fails to Beat OMT in Ischemic Cardiomyopathy: REVIVED-BCIS2 https://www.medscape.com/viewarticle/979853 - Percutaneous Revascularization for Ischemic Left Ventricular Dysfunction https://www.nejm.org/doi/full/10.1056/NEJMoa2206606 - Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction https://www.nejm.org/doi/full/10.1056/nejmoa1100356 II DANCAVAS - DANCAVAS Misses Primary Endpoint but Hints at Benefit from Comprehensive CV Screening https://www.medscape.com/viewarticle/979854 - Five-Year Outcomes of the Danish Cardiovascular Screening (DANCAVAS) Trial https://www.nejm.org/doi/full/10.1056/NEJMoa2208681 - Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure https://www.nejm.org/doi/full/10.1056/NEJMoa1608029 III DELIVER Trial - Dapagliflozin's HFpEF Benefit Recasts Heart Failure Treatment: DELIVER https://www.medscape.com/viewarticle/979855 - Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction https://www.nejm.org/doi/full/10.1056/NEJMoa2206286 - Empagliflozin in Heart Failure with a Preserved Ejection Fraction https://www.nejm.org/doi/full/10.1056/NEJMoa2107038 - SGLT-2 inhibitors in patients with heart failure: a comprehensive meta-analysis of five randomised controlled trials https://doi.org/10.1016/S0140-6736(22)01429-5 IV Rheumatic Heart Disease - Rivaroxaban Outmatched by VKAs for AF in Rheumatic Heart Disease https://www.medscape.com/viewarticle/979861 - Rivaroxaban in Rheumatic Heart Disease–Associated Atrial Fibrillation https://www.nejm.org/doi/full/10.1056/NEJMoa2209051 - Rivaroxaban in Patients with Atrial Fibrillation and a Bioprosthetic Mitral Valve https://www.nejm.org/doi/full/10.1056/NEJMoa2029603 - Outcomes of Direct Oral Anticoagulants in Patients With Mitral Stenosis https://www.jacc.org/doi/full/10.1016/j.jacc.2018.12.047 Features: - Do SGLT2 Inhibitors DELIVER in All Patients With Heart Failure? https://www.medscape.com/viewarticle/979852 - PCI Fails in Stable Disease Again: REVIVED-BCIS https://www.medscape.com/viewarticle/979862 - DANCAVAS: Might Cardiovascular Screening Extend Men's Lives? https://www.medscape.com/viewarticle/979632 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

In this week's episode discuss the efficacy of rivaroxaban as antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer, learn more about the association between genomic variants and survival outcomes after hematopoietic cell transplantation in severe aplastic anemia, and discuss the long-term safety and efficacy of fixed-duration venetoclax plus rituximab in relapsed/refractory CLL.

This week, please join authors John McMurray and David Cherney, editorialist Kausik Umanath, as well as Associate Editors Ian Neeland and Brendan Everett as they discuss the original research articles "Initial Decline (Dip) in Estimated Glomerular Filtration Rate After Initiation of Dapagliflozin in Patients With Heart Failure and Reduced Ejection Fraction: Insights from DAPA-HF" and "Renal and Vascular Effects of Combined SGLT2 and Angiotensin-Converting Enzyme Inhibition" and editorial ""Dip" in eGFR: Stay the Course With SGLT-2 Inhibition." Dr. Carolyn Lam: Welcome to Circulation On the Run, your weekly podcast summary and backstage pass to the Journal and its editors. We're your co-hosts, I'm Dr. Carolyn Lam, Associate Editor from the National Heart Centre and Duke National University of Singapore. Dr. Greg Hundley: I'm Dr. Greg Hundley, Associate Editor and director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Carolyn Lam: Greg, it's the season of double features. Except this time, we're having a forum discussion of two related articles and an editorial that discusses both. What is it on? SGLT2 inhibitors. In the first paper, an analysis from the DAPA-HF trial, looking specifically at that initial dip in GFR that follows initiation of dapagliflozin in patients with HFrEF. Then we will discuss further, in a mechanistic way, the renal and vascular effects of combining SGLT2 inhibition on top of ACE inhibition. Lots and lots of good learning and insights, but let's go on first to the other papers in today's issue. Shall we? Dr. Greg Hundley: You bet, Carolyn, and I'm going to grab a cup of coffee. Carolyn, in this issue, wow, so many exciting original articles. In fact, there are two more articles that were going to pair together, both clinical and pertaining to TAVR procedures. In the first one, it was a group of authors led by Dr. Duk-Woo Park from the Asan Medical Center at the University of Ulsan College of Medicine. They conducted a multicenter, open-label randomized trial comparing edoxaban with dual antiplatelet therapy or DAPT, aspirin plus clopidogrel, in patients who had undergone successful TAVR and did not have an indication for anticoagulation. Now in this study, Carolyn, the primary endpoint was an incidence of leaflet thrombosis on four-dimensional computed tomography, CT, performed at six months after the TAVR procedure. Key secondary endpoints were the number and volume of new cerebral lesions on brain magnetic resonance imaging or MRI and the serial changes of neurological and neurocognitive function between six months and that time immediately post the TAVR procedure. Dr. Carolyn Lam: Oh, interesting. What did they find? Dr. Greg Hundley: Right, Carolyn. In patients without an indication for long-term anticoagulation after successful TAVR, the incidence of leaflet thrombosis was numerically lower with edoxaban than with dual antiplatelet therapy, but this was not statistically significant. The effect on new cerebral thromboembolism and neurological or neurocognitive function were also not different between the two groups. Now because the study was underpowered, the results should be considered really as hypothesis generating, but do highlight the need for further research. Dr. Greg Hundley: Carolyn, there's a second paper pertaining to transcatheter aortic valve prosthesis. It's led by a group directed by Dr. Paul Sorajja from the Minneapolis Heart Institute Foundation and Abbott Northwestern Hospital. Carolyn, these authors prospectively examined 565 patients with cardiac CT screening for HALT, or what we would define as hypoattenuating leaflet thickening, at 30 days following balloon-expandable and self-expanding TAVR. Now, deformation of the TAVR prosthesis, asymmetric prosthesis leaflet expansion, prosthesis sinus volumes, and commissural alignment were analyzed on the post-procedural CT. For descriptive purposes, an index of prosthesis deformation was calculated, with values greater than 1 representing relative midsegment underexpansion. A time-to-event model was also performed to evaluate the association of HALT with the clinical outcomes. Dr. Carolyn Lam: Oh, interesting. What did they find? Dr. Greg Hundley: Right, Carolyn. Nonuniform expansion of TAVR prosthesis resulting in frame deformation, asymmetric leaflet, and smaller neosinus volume was related to the occurrence of HALT in patients who underwent TAVR. What's the take home here, Carolyn? These data may have implications for both prosthesis valve design and deployment techniques to improve clinical outcomes in these patients. Now, Carolyn, both of these articles are accompanied by an editorial from Dr. Raj Makkar from the Smidt Heart Institute at Cedars-Sinai's Medical Center. It's a very lovely piece entitled Missing Pieces of the TAVR Subclinical Leaflet Thrombosis Puzzle. Well, how about we check what else is in this issue? My goodness, this was a packed issue. First, Carolyn, there are three letters to the editor from Professors Ennezat, Dweck, and then a response from Dr. Banovic pertaining to a follow-up from a previously published study, the AVATAR study, in evaluating valve replacement in asymptomatic aortic stenosis. There's also a Perspective piece from Dr. Wells entitled “Treatment of Chronic Hypertension in Pregnancy: Is It Time For A Change?” There's a Global Rounds piece from Professor Berwanger entitled “Cardiovascular Care in Brazil: Current Status, Challenges, and Opportunities.” Then there's also a Research Letter from Professor Eikelboom entitled “Rivaroxaban 2.5 mg Twice Daily Plus Aspirin Reduces Venous Thromboembolism in Patients With Chronic Atherosclerosis.” Dr. Carolyn Lam: There's another Research letter by Dr. Borlaug on longitudinal evolution of cardiac dysfunction in heart failure with normal natriuretic peptide levels. There's also a beautiful Cardiology News piece by Bridget Kuehn on the post-COVID return to play guidelines and how they're evolving. Well, that was a great summary of today's issue. Let's hop on to our feature forum. Shall we? Dr. Greg Hundley: You bet, Carolyn. Can't wait. Dr. Carolyn Lam: Today's feature discussion is actually a forum because we have two feature papers in today's issue. They all surround the cardiorenal interaction, should I say, of the SGLT2 inhibitors. For the first paper, discussing that initial decline or that dip in the GFR following initiation of dapagliflozin would be Dr. John McMurray, who's the corresponding author of this paper from DAPA-HF. Dr. John McMurray's from the University of Glasgow. Now next, we have also the corresponding author of another paper, really going into the mechanistic insights of the renal and vascular effects of combined SGLT2 and ACE inhibition. Dr. David Cherney is from Toronto General Hospital, University of Toronto. Dr. Carolyn Lam: We have the editorial list of these two wonderful papers, Dr. Kausik Umanath from Henry Ford Health in Michigan. Finally, our beloved associate editors, Dr. Ian Neeland from Case Western Reserve and Dr. Brendan Everett from Brigham and Women's Hospital, Harvard Medical School. Thank you, gentlemen. Now with all of that, what an exciting forum we have in front of us. Could I start by asking, of course, the respective authors to talk a little bit about your papers? I think a good place to start would be with Dr. McMurray. John, please. Dr. John McMurray: Thanks, Carolyn. I think our paper had three key messages. The early dip in eGFR that we saw was, on average, very small in patients with heart failure, about 3 mLs/min or about 5%. Very few patients had a large reduction in the eGFR. It was around 3%. Dapagliflozin-treated patients had a 30% or greater decline compared to about 1% of placebo patients. Finally, very few of those patients had a decline in the eGFR below a critical threshold, which for cardiologists might be around 20 mLs/min. We saw that in only five patients; that's 0.2% of the dapagliflozin-treated patients. Second message was that that early decline partially reverses. The nadir in our study was about 14 days. But by 60 days, on average, eGFR had increased again. Hold your nerve if you see an early decline in eGFR.   Dr. John McMurray: Maybe the most important message was that that decline in the eGFR is not associated with worse cardiovascular or renal outcomes. In fact, if anything, the opposite. If you look at the patients in the dapagliflozin group with a 10% or greater decline in eGFR, then compare it to patients who didn't have that decline, these individuals were about 27% less likely to experience the primary composite outcome of worsening heart failure and cardiovascular death. If you look at the placebo group, we saw exactly the opposite. Amongst those who had a greater than 10% decline in eGFR compared to those who didn't, those people with the early decline in eGFR were 45% more likely to experience the primary composite endpoint. The same is true for other cardiovascular outcomes for worsening kidney function. In the dapagliflozin group, decline in eGFR was not associated with more adverse events, not associated with more treatment discontinuation. That small decline in the eGFR is not a bad prognostic sign. If anything, it might be the opposite. Dr. Carolyn Lam: Thank you so much. That was really clear. David, are you going to tell us why this decline occurs? Dr. David Cherney: Yeah. Perhaps the paper that we published gives some insights into the mechanisms that are responsible for some of those changes in GFR that are thought to be acute hemodynamic effects. In the between trial, which is the trial that we published examining the effect of ACE inhibition followed by SGLT2 inhibition in patients with type 1 diabetes, we also saw that there was an expected effect of adding SGLT2 inhibition on top of an ACE inhibitor in people with uncomplicated type 1 diabetes. This acute dip in GFR was seen in this cohort of patients. We included only 30 patients in this small mechanistic study. At the same time, along with that dip in GFR, we also saw an increase in measures of proximal natriuresis. That proximal sodium loss is linked with changes in sodium handling in the kidney, which then causes changes in both probably afferent and efferent tone, which causes this dip in GFR primarily through natriuresis in this phenomenon called tubuloglomerular feedback. That was one major observation that gives insight into what we see in larger trials around the dip in GFR. Dr. David Cherney: In our mechanistic study, we also saw an additive effect on blood pressure. Blood pressure went down further with the addition of empagliflozin on top of an ACE inhibitor. In terms of the mechanisms that are responsible for the reduction in blood pressure, natriuresis certainly may be in part responsible, but we also saw a novel observation whereby there was a reduction in peripheral vascular resistance using noninvasive measures. There are likely several mechanisms that are responsible for the reduction in blood pressure. Then finally, we also saw reductions in markers of oxidative stress, which may also account for some of the effects that we see in blood pressure, as well as potentially some of the anti-inflammatory and anti-fibrotic effects that we see at least in experimental models that may have some clinical translatability to humans as well around the clinical benefits. I think the blood pressure, the renal hemodynamic effects, and some of the neurohormonal mechanisms are the major observations that we saw that may in part explain some of the really nice changes that were seen in Dr. McMurray's study. Dr. Carolyn Lam: Right. Thanks, David. But these were patients with type 1 diabetes and no heart failure. John, do you have any reflections or questions about how that may apply? By the way, what a beautiful study. Thank you, David. Dr. David Cherney: Pleasure. Thank you. Dr. John McMurray: Yes, David. I really enjoyed your study. In fact, I think, Carolyn, it does shed some insights perhaps to what's going on. As David pointed out, the reduction in peripheral arterial resistance, reduction in blood pressure, that may play some role in that early dip in eGFR as well as autoregulation in the kidney. Then the other interesting thing is that the distal nephron seems to adapt to that effect in the proximal tubule. Again, that may account for some of that recovery in eGFR, that reversal in the early dip that I spoke about, and which I think is very clinically important because, of course, physicians should make sure that they recheck eGFR if they see that early dip. Because they may find that few weeks later that that dip is much smaller and of much less concern. Dr. Carolyn Lam: Thank you, John. In fact, you're saying, stay the course, right- Dr. John McMurray: I have. Dr. Carolyn Lam: ... with the SGLT2 inhibitors. I'm actually stealing the words of the title of the editorial, a beautiful editorial by Kausik. I love that. Stay the course. Kausik, please, could you frame both papers and then with an important clinical take home message for our audience? Dr. Kausik Umanath: Sure. I think the analysis by John and his group was really relevant with the large sample size. What's impressive? Similar to a lot of these other SGLT2 studies that have come out, both in heart failure and in kidney disease progression and so on, it's remarkable how the other analysis, like the analysis of EMPA-REG and CREDENCE and so on, of similar dips. All show more or less the same magnitude, the same relative proportions of this GFR trajectory. I think the mechanistic study only highlights that though it's working with a slightly different population of type 1 patients and much earlier in their course in terms of where their GFRs are. Dr. Kausik Umanath: The other piece is that ultimately we need to understand this dip and know to monitor for it and so on. But I think the general clinician should really understand that a dip of greater than 10% really occurs in less than half the population that takes these agents. That dip, if it occurs, certainly doesn't do any harm. That said, if they see a bigger dip in the 30% range, monitor more closely and consider making sure that there aren't any other renal issues out there for that patient because they are a much smaller proportion of patients in these large trials that generate that level of dip. They should be monitored. Dr. Kausik Umanath: The other thought that we had, and thinking through this in a practical sense, is because you expect this dip, many of our cardiologists or even the nephrologists when we titrate these drugs, they're on a suite of other drugs. It's probably best to not adjust their Lasix or their loop diuretic, or their RAAS inhibitor at the same time as you're adjusting the SGLT2 inhibitor or starting it because then you may just introduce more noise into the GFR changes that you see over the next several weeks. It may be a sequential piece or at least holding those other agents constant while this gets titrated and introduced is a prudent course of action, so you don't misattribute changes. Dr. Carolyn Lam: Thanks so much. What clinically relevant points. In fact, that point about the diuretic especially applies in our heart failure world. You see the dip. Well, first, make sure the patient's not overdiuresed. Remember, there's more that the patient's taking. Thank you. That was a really great point. Brendan and Ian, I have to get you guys to share your views and questions right now. But before that, can I take a pause with you and just say, aren't you just so proud to be AEs of Circulation when we see papers like these and we just realize how incredible the data are and the clinical implications are? I just really had to say that. All right. But with that, please, what are your thoughts, Brendan? Dr. Brendan Everett: Yeah, sure. Thank you, Carolyn. Hats off to all three of our authors today for doing some amazing science. Thank you for sending it to Circulation. I think, in particular, I handled David's paper. I'm not a nephrologist and I'm probably the furthest thing from a nephrologist. Had to do my best to try and understand these concepts that I'm not sure I ever even was exposed to in medical school many years ago. I think it shows the breadth of the interest in our readership. The fact that these changes in eGFR have become a primary focus for our cardiovascular patients and that the clinical implications are really important. I guess my question, David, is... In your paper, you talked a little bit about this hypothesis of hyperfiltration and the role that hyperfiltration plays in setting patients with diabetes up for kidney disease. Is that playing a role in John's observation or not? Again, as a non-nephrologist, I have trouble connecting the dots in terms of that hypothesis and John's observation of the clinical benefit for patients that have a reduction in eGFR as opposed to no change. Dr. David Cherney: Yeah. It's a great question. It's very difficult to know with certainty in a human cohort because we can't measure the critical parameter, which is intraglomerular pressure, which we think these changes in GFR are a surrogate for. But if we go along with that train of thought, along reductions in glomerular hypertension, it very much makes sense that the patients who dip are those who have the... They're taking their medication, number one. Number two, they respond physiologically in the way that you expect them to, which is that their GFR dips at least transiently and then goes back up again through some of the compensatory mechanisms that John mentioned earlier. As was mentioned not only in this paper, but also in previous analyses from CREDENCE and previous analyses from VERTIS CV and others have shown that indeed that dip in GFR is linked with longer term renal benefits, at least. That is reflected in a reduction in the loss of kidney function over time. Dr. David Cherney: The patients who are on an SGLT2 inhibitor and those who dip by around 10% or less, those patients tend to do the best over time in terms of preserving GFR, not losing kidney function compared to patients who are on an SGLT2 inhibitor but do not dip, or those patients who actually have an increase in GFR. That is consistent with this idea that there may be a reduction in glomerular pressure, which is protective over the long term. That ties back into your question around hyperfiltration that this may indeed be due to a reduction in glomerular pressure, which is linked with risk over the long term. Dr. Carolyn Lam: Ian? Dr. Ian Neeland: I wanted to echo Brendan's comments about the excellent science. When I read these papers, it really speaks to the existential struggle that cardiologists have between kidney function and these medications that we know have cardiovascular benefits. How do we manage that practically? It's so clinically relevant, both the observation that John's paper made about the dip in the DAPA-HF trial as well as, David, your mechanistic insights. Dr. Ian Neeland: I wanted to ask John potentially about the most fascinating aspect to me of this paper was that patients with a dip of 10% or more actually ended up doing better in terms of cardiovascular outcomes, specifically hospital heart failure and hospitalizations than people on placebo with a greater than 10% dip. It speaks to the fact that... Is the physiology going on here different between those individuals whose GFR went down on placebo versus those who are on SGLT2 inhibitors? All the mechanistic insight that David's paper had in terms of blood pressure and intraglomerular pressure, how does that feedback and speak to why heart failure is strongly linked to this mechanism? We see this not just with SGLT2 inhibitors, but there are other medications now coming out showing that there's a relationship between this dip in GFR and heart failure. Can you speak to why this heart failure-kidney connection is so important and becoming greater and greater in terms of our understanding? Dr. John McMurray: Well, thank you for asking me the hardest question and one that I truly don't think I have a good answer to. I think it's obvious to all of us that the kidney is central in heart failure and perhaps cardiologists have neglected that fact, focusing more on the other organ. But by definition, almost the fluid retention that characterizes heart failure in terms of signs, and probably is the primary cause of symptoms, that clearly is a renally-mediated phenomenon. The kidney must be central to all of this. I think David right. I think the decline in eGFR that you see with this drug is simply a marker that the drug is having its physiological effect or effects. Whatever those are, they're beneficial. Clearly, patients who have an eGFR decline on placebo are different and they reflect, again, the patients that we see all the time. As our patients with heart failure deteriorate, one of the things that we commonly see, in fact becomes one of the biggest problems that we have to deal with, is that their kidney function declines. As their symptoms get worse, as their cardiac function gets worse, their kidney function also declines. Dr. John McMurray: I think you're seeing two contrasting effects here. One is the background change in eGFR, which is the placebo patients, and we've always known that that's a bad thing. Then we're seeing that early within 14 days marker of the pharmacological or physiological action of the drug. I hope you don't ask me how SGLT2 inhibitors work in heart failure. That's the other most difficult question I can think of, but I think this is just a marker of the fact that they are working. Dr. David Cherney: Yeah. Just to add to that briefly, there is this difficulty in sorting out the mechanisms that are relevant around the acute effects in the kidney that the dip in GFR reflects natriuresis that could keep patients out of heart failure; that the reduction in glomerular pressure reduces albuminuria. Albuminuria reduction is linked with kidney protection. It's linked with heart failure and ASCVD protection. Then there's also this concept of if you dip and then you stay stable afterwards, your GFR stays stable afterwards, those patients with stable kidney function that's not declining, the dippers in other words, those patients are probably able to maintain salt and water homeostasis better than someone who's declining more rapidly. All these things probably tie together in order to reflect, of course, there's a renal protective effect, but that some of those mechanisms may also tie into the heart failure mechanisms that John was mentioning. Dr. John McMurray: But, David, it's hard to imagine if we don't protect the kidney, we won't protect patients with heart failure given how fundamental, as I said, the kidney is, and how fundamentally important worsening kidney function is. Not only because it is a marker of things going badly, but also because it often results in discontinuation or reduction in dose of other life-saving treatments. To Kausik's point, it was very important about the risk of changing background life-saving disease modifying therapy. Actually, we didn't see that in DAPA-HF, which was very intriguing. There was no reduction in use of renin-angiotensin system blockers or mineralocorticoid receptor antagonists. Dr. Carolyn Lam: Thank you so much, gentlemen. Unfortunately, we are running out of time, but I would really like to ask one last question to the guests, if possible. Where do you think the field is heading? What next? What's the next most important thing we need to know? David, do you want to start? Then John, then Kausik. Dr. David Cherney: I think one of the aspects that we need to know in the future is where else can we extend these therapies into novel indications and extend the boundaries of where we currently work with these therapies. People with type 1 diabetes, for example, with either heart failure or with significant kidney disease, patients with kidney transplantation, is there a renal or cardiovascular protective effect? Then another high risk cohorts who have not been included in trials, those on immunosuppressants, for example, who were excluded from the trials. I think those are some of the areas that we need to extend into now that we understand how these therapies work in even very sick patients and that we also know that they likely have at least some benefit through suppressing inflammation, and possibly reducing infectious risks. That would provide a rationale for extending into some of these new areas. I think that's certainly, hopefully on the horizon for us. Dr. Carolyn Lam: John? Dr. John McMurray: Carolyn, obviously I think looking at post myocardial infarction population, that's an obvious place to go. There are a couple of trials there. I suppose the trial that I would love to see, and which I think would address the core question that we've been discussing today, which is: Is this all about the effect in the kidney and how important is the diuretic and natriuretic action of these drugs in heart failure? I think the key study that would address this would be doing a study in patients on dialysis. Because in those patients we could, I think, separate the issue of natriuresis, diuresis, and maybe even the dip in EGR that we've been talking about. If these drugs prove to be effective in end-stage kidney disease, patients on dialysis, that would be really fascinating. Dr. Carolyn Lam: Kausik? Dr. Kausik Umanath: That is a very interesting point. I don't know that we know necessarily outcomes, but I think from working with the DAPA-CKD, we do have a little bit of the safety data because we did continue it. I was the US MLI for that study and we did continue the SGLT2 passed into renal failure. There is a little bit of safety data there. But I don't think once you've declared an outcome, you're not collecting outcomes data after that point. That's a very interesting area to look into. Dr. Kausik Umanath: I also think the other place where this field's heading is trying to better tier and layer the multitude of agents. I think we've been waiting for about 20 to 30 years, at least in the kidney field, for something new to affect the progression of kidney disease after the ACE/ARB trials and so on. This one we've got SGLT2 inhibitors. We've got the new MRA, finerenone, and so on, which also have very beneficial cardiovascular effects. The question becomes: How do we layer these therapies? Which sequence to go in? Some of the others that are in pipeline as well that are out there that have very beneficial cardiovascular effects that may indeed also help kidney function and diabetes control, which do you go with first and so on? Dr. Carolyn Lam: Wow! Thank you so much. We really could go on forever on this topic, but it has been tremendous. Thank you once again. On behalf of Brendan, Ian, Greg, thank you so much for joining us today in the audience. You've been listening to Circulation On the Run. Don't forget to tune in again next week. Dr. Greg Hundley: This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

Show notes at pharmacyjoe.com/episode731. In this episode, I'll discuss a company-sponsored indirect comparative study looking at andexanet alfa vs 4 factor prothrombin complex concentrate (4FPCC) for the reversal of apixaban- or rivaroxaban-associated intracranial hemorrhage. The post 731: Company sponsored indrect comparison concludes the company’s product is better for the reversal of apixaban- or rivaroxaban-associated intracranial hemorrhage appeared first on Pharmacy Joe.

Show notes at pharmacyjoe.com/episode731. In this episode, I ll discuss a company-sponsored indirect comparative study looking at andexanet alfa vs 4 factor prothrombin complex concentrate (4FPCC) for the reversal of apixaban- or rivaroxaban-associated intracranial hemorrhage. The post 731: Company sponsored indrect comparison concludes the company’s product is better for the reversal of apixaban- or rivaroxaban-associated intracranial hemorrhage appeared first on Pharmacy Joe.

This week, please join author Roderick Tung, editorialist William Stevenson, and Associate Editor Sami Viskin as they discuss the article "First-Line Catheter Ablation of Monomorphic Ventricular Tachycardia in Cardiomyopathy Concurrent with Defibrillator Implantation: The PAUSE-SCD Randomized Trial" and the editorial "Can Early Ablation of Ventricular Tachycardia Improve Survival?" Dr. Greg Hundley:           Welcome listeners to this June 21st, 2022 issue of Circulation on the Run. And I'm Dr. Greg Hundley, associate editor and director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Listeners, what a very interesting forum that we're going to have in this session today with Dr. Rod Tung, bringing us an article from first line catheter ablation of monomorphic ventricular tachycardia in cardiomyopathy with concurrent defibrillator implantation. Some results from the Pause sudden cardiac death randomized clinical trial. This article is really interesting because it is collecting data from multiple centers from multiple countries in Asia. But before we get to that article, why don't we grab a cup of coffee and go through some of the other articles in the issue? Well, the first is entitled cardiovascular magnetic resonance for rejection surveillance after cardiac transplantation. And it comes to us from Dr. Jim Pouliopoulos from the Victor Chang Cardiac Research Institute. In this study, CMR based multiparametric mapping was initially assessed in a prospective cross-sectional fashion to establish agreement between cardiovascular magnetic resonance and endomyocardially based measures of cardiac rejection and determine the CMR cutoff values between various cardiac rejection grades. Then after that, a prospective randomized noninferiority pilot study was undertaken in adult orthotopic heart transplant recipients who were randomized at four weeks post orthotopic heart transplant to either CMR or endomyocardially based rejection surveillance. And clinical endpoints were also assessed at 52 weeks. And so listeners, what did this investigative team find? Well, despite similarities in immunosuppression requirements, kidney function and mortality between the groups, the rates of hospitalization and the rates of infection were lower in the CMR group. On 15 occasions, patients that were randomized to the CMR arm underwent endomyocardial biopsy for clarification or logistic reasons, representing a 94% reduction in the requirement for endomyocardially based surveillance. And so listeners, a noninvasive CMR based surveillance strategy for evidence of rejection in the first year after orthotopic heart transplantation is feasible. And interesting, listeners, these results really suggest the possibility for further studies to confirm whether CMR and perhaps in combination with other modalities could be used to survey orthotopic heart transplant patients for acute rejection without necessarily having to undergo endomycardial biopsy. There's an excellent editorial by Dr. Jim Fang from the University of Utah who also reviewed this paper. Well, listeners, let's next turn to the world of preclinical science. And this paper comes to us from professor Simon Sedej from Medical University of Graz. It involves the insulin and insulin growth factor one or IGF-1 pathway. And that is known as a key regulator of cellular metabolism and aging. Now, although its inhibition promotes longevity across species, the effect of attenuated IGF-1 signaling on cardiac imaging really remains controversial. So what did the authors find? Well, they found that cardiomyocyte IGF-1R over expression in mice resulted in physiological hypertrophy and superior cardiac function in early life, but led to accelerated cardiac aging, heart failure and reduced lifespan in late life. Mechanistically, increased cardiomyocyte IGF-1R signaling accentuated cardiac dysfunction by reducing autophagy and mitochondrial oxidative capacity at old age, and therefore clinically pharmacologic inhibition of cardiac IGF-1R signaling in late life could suppress the age related deterioration of cardiac performance and perhaps increase lifespan. And therefore age should be considered as a major outcome determinant in future clinical trials, testing IGF-1R P13K inhibitors for cardiac benefits. Well listeners, what is our next study? And this study is somewhat related to our feature discussion, which we'll get to in a few minutes. It's from Dr. Paolo Della Bella from San Rafael Hospital, and it is a two phase prospective multicenter randomized clinical trial that was performed to evaluate the benefit of ablation after first implantable cardiovert defibrillator, or ICD shock. And patients with ischemic or nonischemic dilated cardiomyopathy and primary or secondary prevention indication for ICD were enrolled in an initial observational phase until first appropriate shock. And that was phase A of the study. Then afterwards, they were re-consented and patients were randomly assigned in a one-to-one fashion in the second phase or phase B to immediate ablation. That's within two months from shock delivery or continuation of standard therapy. And the primary endpoint of the study was a composite of death from any cause or hospitalization for worsening heart failure. And amiodarone intake was not allowed except for documented atrial tac-arrhythmias. So listeners, what were the results from this trial? Well, ventricular tachycardia ablation after first appropriate shock was associated with a reduced risk of the combined endpoint of death or worsening heart failure for hospitalization, lower mortality and fewer ICD shocks. And these findings therefore provide support for considering ventricular tachycardia ablation after the first ICD shock. Now this study and the feature which will be coming up in a few minutes is nicely reviewed in an editorial from Bill Stevenson at Vanderbilt University. Well listeners, what other articles are in this issue? Well, from the mail bag, we have a research letter from Professor Solomon entitled Health Status Trajectories Before and after hospitalization for Heart Failure. Also, there is a second research letter from Professor Eikelboom entitled Rivaroxaban 2.5 Milligrams Twice Daily Plus Aspirin Reduces Venous Thromboembolism in Patients with Chronic Atherosclerosis. And then next there's an ECG challenge from Professor Rosenfeld entitled Around and Around, a Wide Complex Tachycardia. Well listeners, what a great series of articles. And now we're going to get on and visit with Rod Tung, Sami Biskin and Bill Stevenson to evaluate first line catheter ablation of monomorphic ventricular tachycardia in cardiomyopathy, concurrent with defibrillator implantation. Well, listeners, welcome to this June 21st feature discussion. And we're very fortunate today to have with us Dr. Roderick Tung from the University of Arizona in Phoenix. We also have our own associate editor, Dr. Sami Viskin from Tel Aviv Medical Center in Tel Aviv, Israel, and Dr. Bill Stevenson from Vanderbilt University in Nashville, Tennessee. Welcome gentlemen. Well, Roderick, we're going to start with you. Rod, can you describe for us some of the background information that went into the construct of your study and what was the hypothesis that you wanted to address? Dr. Roderick Tung:          Well, thank you, Greg, Pause is really the culmination of a lot of personal academic and cultural exchanges between many Asian centers and particularly in China. In terms of exchanges, where we would go across overseas, do a lot of different VT cases. And this all started in about 2013. And at that point in time, I was struck by a lot of differences that we were seeing, particularly whenever they wanted us to do a case, it tended to be a nonischemic etiology patient, and they always wanted to see some sort of epicardial procedure. And these are the ones that are enriched for epicardial substrates. As many listeners know, the ischemics tend to have more endocardially based scars. And that's why epicardial BT ablation is typically reserved for those that either have failed endocardial or those ARVC patients or non-ischemic cardiomyopathy. So that was the first thing, is there's a paucity of ischemic cardiomyopathy in Asia, which is still inexplicable. The second thing that was really interesting in my observations going to Asia was that the defibrillator penetration and adoption is not widespread like it is in America. And in a very Amero-centric view, we always think that, oh, well, everything else is a departure from a standard of care. Well, when you look at 1.4 billion people, that's a really significant population at risk for sudden death that's not being treated the same way that we typically see it in a lot of Western cultures. So I felt like it was a perfect fertile grounds for clinical exploration. And that's really where Pause was born, is to be able to look at the impact of catheter ablation and ICD therapies on the risk of sudden death. And that's really how the trial began. Dr. Greg Hundley:           And what was the hypothesis, Rod, that you wanted to address? Dr. Roderick Tung:          Well, when we started designing Pause in 2014, 2015, there had only been two prior trials that were published and that was Smashed VT in New England Journal. And then there was VTAC by Karlheinz Cook in Lancet. So really the hypothesis was to be able to assess whether preemptive or first line catheter ablation at the time of defibrillator implantation, which is not what we do in the US, we usually wait till there's therapies, if that decreases the composite endpoint of recurrent VT cardiovascular hospitalization mortality. Dr. Greg Hundley:           Very nice. And so describe for us, Rod, your study population, and then the design that you use to address the hypothesis. Dr. Roderick Tung:          So this was a randomized controlled trial, multicenter across 11 centers in China, Korea, Japan, Taiwan. These were really well respected and regarded academic centers. I do want to give a shout out to many of them, Kyoko Sojima, who trained with Bill Stevenson, wrote so many seminal papers in VT. In Japan, Akid Nogogami who really was charged with and responsible for opacity some of the mechanisms of particular VT, then there's Yao Yin in Beijing who's done great work in atrial fibrillation, cardiac neuroablation. Ming Long Chen, Chan Yang Jeng. So some really great names, and it was done over 11 centers, one to one randomization between control, which was just ICD, and the active arm was ICD with catheter ablation within 90 days of the ICD implantation. Dr. Greg Hundley:           And how many patients, and then what were your study results? Dr. Roderick Tung:          So we ended up with 121 patients that were randomized, 61 versus 60, 180 were eligible and screened. And what was really also different about this trial compared to others is that we involved a non-randomized registry. Those were patients that refused to be randomized, and most typically didn't want to have a defibrillator. And that's where the cultural differences of ICD acceptance are different. For two reasons. Number one, physicians actually don't truly believe a lot of the defibrillator data is relevant to non ischemics in Asia and the Asian population. So there's actually a little bit of an academic barrier of generalizing historical ICD data to Asia, which I observed with a lot of the physicians. And number two, patients sometimes don't want that technology in there, and they have different ideas of sudden death. So these patients were actually put into a registry and followed prospectively with catheter ablation alone without background ICD therapy. And that's very unique because the amount of data that has been prospectively followed for ablation sans ICD therapy is very few. So that was 47 in the registry. And there was 121 that was one to one randomized. Dr. Greg Hundley:           And what did you find? Dr. Roderick Tung:          Well, we found that those that underwent concomitant ablation with their ICD implantation that presented with monomorphic VT had a lower rate of the composite triple endpoint of VT recurrence, cardiovascular hospitalization, and death. This was largely driven by a nearly 20% absolute risk reduction in VT recurrence. There was a 4% absolute risk reduction in cardiovascular hospitalization, but this is not significant. And mortality rates were low. It was seven and 8% in those arms. So one of the things that we were hoping to get to was actually looking at mortality, but I think this is challenging with background ICD therapy there. And number two, it's challenging because mortality rates are lower in non-ischemic cardiomyopathy. And that's because they don't have the concomitant comorbidities of peripheral vascular disease, coronary artery disease, older age, cetera. So we actually had a pretty low rate of mortality, which we were hoping to get to, but that wasn't able to be assessed in this because of the low rates. Dr. Greg Hundley:           Very nice. Well, now listeners, we're going to turn to our own associate editor, Dr. Sami Biskin. And Sami, many papers come across your desk. What attracted you to this particular study? Dr. Sami Viskin: Well, we need to better define what is the optimal timing for VT ablation in patients with the organic heart disease. As we have seen many patients that are referred too late for ablation, where they already have an arrhythmic storm and recurrent shocks. And on the other hand, we have seen studies like the Berlin Study from Cook that fail to show any benefit on endpoints like heart failure or mortality. So the study by Tung arrived shortly after the different study by Paolo Della Bella, the PARTITA study, that was also studying patients at an earlier stage. So in the Partita study, they were studying patients at the time of the first ICD shock. And then Rod came with this study where he studied patients at the time of ICD implantation. Now, usually authors ask to get an executive review of their article. In this occasion, we as the editors, we saw the opportunity and asked Rod to submit his paper as fast as possible and made the correction as soon as possible so we could get the two papers dealing with early VT ablation in the same issue with an invited editorial by Dr. Stevenson so we could put everything in context. Dr. Greg Hundley:           Very nice. Well, Bill, Sami has set you up very nicely here. And as the editorialist, help us put these results from Rod into the context of what we know already today in this sphere of investigation pertaining to VT shocks, defibrillator implantation. Dr. William Stevenson:  Yeah. So first I want to congratulate Rod on a very important study. It has been so difficult to conduct randomized trials of VT ablation and intervention, and to be able to bring this to fruition and internationally in Asia is really quite an accomplishment. We definitely need more information that guides us as to when VT ablation should be performed in people who have defibrillators and are having spontaneous episodes of VT. And we know that in patients with ischemic heart disease, with coronary artery disease, post infarct VTs, that catheter ablation can reduce the episodes of recurrent VT and reduce shocks from VT. And this is a very important quality of life issue for patients with defibrillators. But we haven't really had good data, certainly not randomized multicenter data in other patient populations. And we still are grappling with, does a reduction in VT episodes improve other outcome measures? Does it really improve quality of life? Does it reduce hospitalizations? Does it translate to a reduction in mortality? And so Rod's study, one of the strengths of it being in Asia is that there were a lot of patients who had non-ischemic causes of heart disease. And more than a third of patients had arrhythmogenic right ventricular cardiomyopathy, and his study makes it clear that those patients really benefit substantially with a reduction in VT episodes. And that overall, VT episodes are reduced in all three of the subgroups of different diseases, the ARVC and the ischemics and the non ischemics that were included in the trial. But I think it's worth digging in a little more to the non-ischemics, because they did not seem to receive the benefit that the arrhythmogenic right ventricular cardiomyopathy and the ischemic cardiomyopathy patients received. So that the efficacy was largely driven by the benefit in the ischemics and the ARVC patients. So one of the important considerations I think is when you're in your office with a patient who has a defibrillator and has had episodes of VT, and you're considering does this patient need a VT ablation? I think that if they've got ischemic cardiomyopathy, this data strongly supports that approach. If they've got arrhythmogenic right ventricular cardiomyopathy, again, ablation is very likely to reduce their episodes of VT/ for the non-ischemic group, which is about a third of the patient population that Rod studied, the data are less convincing in that group. And we know that's a harder group to achieve success with, with ablation. So we'll definitely want more data in that group. And I'm looking forward to some of the more detailed and sub-study sorts of analyses that I'm sure Rod is planning. Dr. Greg Hundley:           Very nice, Bill. Well, listeners, and Bill you've teed it up nicely to really sort of circle back through each of you and ask, what is the next study to be performed in this space? So we'll start with Rod and then Sami, and then finish up with you, Bill. So Rod, what is the next study that you see needs to be performed really in follow up to yours? Dr. Roderick Tung:          Well, we're thinking Pause too might be a nice just ARVC study alone, because again, inexplicably, there's a very high incidence of ARVC in Asia, and I was always taught that this was a disease from the Veneto region of Italy. And that might not be the case, or there's a lot of sarcoid mimicking of it as ARVC and undiagnosed. But we're thinking about a Pause too being an ARVC study, maybe without background I,CD therapy with background ICD therapy, this might provide justification for that. Because again, those in the registry did quite well, but that's because they were younger and had ARVC and normal LV function. So that might be a nice area to explore worldwide. And then lastly, just to put things in perspective for the Circ listeners, you need 8,400 patients in paradigm to show benefit mortality and heart failure hospitalization for an ARNI. Right? For IRNESTO. We're talking about 120 patient studies when we talk about VT ablation, with these very complex ablation trials. So I think we just need larger trials. And the hard thing for us as VT ablation centers is we often will get patients that have had recurrent VT after a failed procedure. So it's hard to come by these that are very early, but I think we need 500 patient studies, a thousand patient studies. And also for the listeners, it's very hard to show mortality reduction with a background ICD therapy. And that's the problem, is that ICD is so effective as an abortive treatment that it's very hard to show reduction and mortality. You'd have to show it in terms of heart failure. Dr. Greg Hundley:           Very nice, Rod. And Sami, what would you like to add? Dr. Sami Viskin: Oh, obviously the last word on the optimal timing of VT ablation is not out there. And we need more studies to really define when is the appropriate time for the VT ablation. That's what we need. Dr. Greg Hundley:           Very good. And Bill? Dr. William Stevenson:  Yeah, I agree with Sami. And with rod, we need larger studies to assess the benefit, to really help guide our clinical decision making that can get at quality of life issues as well as the mortality and cardiovascular hospitalization issues in even more detail. But this is a wonderful first initial step into the ischemic, non-ischemic and ARVC populations. Dr. Greg Hundley:           Very nice. Well listeners, we want to thank Dr. Rod Tung from university of Arizona, Phoenix, Dr. Sami Viskin from the Tel Aviv Medical Center in Tel Aviv, Israel, and Dr. Bill Stevenson from Vanderbilt University in Nashville, Tennessee, for bringing us this study that highlighting among patients, particularly with ARVC in an ischemic cardiomyopathy from Asia across multiple centers in different countries that early catheter ablation performed at the time of ICD implantation really reduced the composite primary outcome of VT recurrence, cardiovascular hospitalization, or death. And these findings were really nicely driven by a reduction in the ICD therapies. Well, on behalf of Carolyn and myself, I want to wish you a great week and we will catch you next week, on the run. This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

In this episode, we discuss the clinical manifestations, diagnosis and management of peripheral arterial disease. Our medicine minute focuses on emerging evidence for the use of Rivaroxaban following the release of the COMPASS trial in 2020. Written by: Dr. Palki Bhatt (Internal Medicine)Reviewed by:  Dr. Sonia Anand (Cardiology) and Dr. Kajenny Srivaratharajah (General Internal Medicine)Sound Editing by: Dr. Alison LaiThis episode was supported by Spatula Foods. Enjoy elevated cuisine every day with high-quality dishes you can cook yourself in just 10 minutes. Go to https://www.spatulafoods.com and use promo code INTERN for $40 off your first box- this will help support our podcast! Support the show

Today we are joined by Dr. Brian Locke to talk about the newest big trial on IV fluids in critically ill patients and a meta-analysis that looks at all the similar trials. Is this question finally settled?We also look at PICC lines vs midlines, IV L-ornithine L-aspartate in acute treatment of hepatic encephalopathy, a new ward-based program for delirium prevention in older inpatients, post-discharge thromboprophylaxis for high risk COVID patients, and whether mindfulness training can help burnout in residents.Balanced Multielectrolyte Solution vs Normal Saline in Critically Ill Patients (PLUS)Balanced Crystalloid vs Normal Saline Meta-analysisPICC lines vs MidlinesApixaban vs Rivaroxaban for Recurrent VTE LOLA for Hepatic EncephalopathyEat-Walk-Engage in Older Inpatients (CHERISH)Rivaroxaban for Post-discharge Prophylaxis in High Risk COVID patients (MICHELLE)Mindfulness Training and BurnoutMusic from Uppbeat (free for Creators!):https://uppbeat.io/t/soundroll/dopeLicense code: NP8HLP5WKGKXFW2R

Rivaroxaban on board for CCS

Rivaroxaban versus warfarin in APS

The findings of COMPASS trial

Rivaroxaban vs Apixaban in AF

Low dose Rivaroxaban in SIHD, COMPASS trial

Insights from COMPASS-PCI & COMPASS-CABG Trials

Insights from COMPASS & VOYAGER Trials

It's our last episode in 2021! This episode we have Dr. Libo Wang and Dr. Jon Harrison on to talk about their new paper in the Annals of Internal Medicine about ultrasound JVP for estimating CVP, validated with right heart catheterization. We also ask them their thoughts on a new meta-analysis looking at metoprolol vs diltiazem for atrial fibrillation with RVR. We also look at a new large retrospective study of apixaban vs rivaroxaban for stroke prevention, a study looking at reducing sleep interruptions in the hospital, and two new outpatient therapies for COVID-19 infection. Happy New Year! Ultrasound JVP for estimating CVPIV Diltiazem vs Metoprolol for A fib with RVRMajor Ischemic and Hemorrhagic Events in Apixaban vs Rivaroxaban for AFReducing Sleep Interruptions in Hospitalized Patients Early Remdesivir for Outpatient COVID-19Molnupiravir for Outpatient COVID-19Music from Uppbeat (free for Creators!):https://uppbeat.io/t/soundroll/dopeLicense code: NP8HLP5WKGKXFW2R

Somehow we got through 7 articles today, and none of them are about COVID-19! Happy Thanksgiving! Chlorthalidone in CKDMilvexian for VTE PreventionRisk of Recurrent VTE in Subsegmental PERivaroxaban associated with higher rates of GI bleedingDepression and ResidencyMental-Stress Induced Myocardial IschemiaPatient Outcomes for Part Time HospitalistsMusic from Uppbeat (free for Creators!):https://uppbeat.io/t/soundroll/dopeLicense code: NP8HLP5WKGKXFW2R