Daily Cardiology Research Analysis

BACKGROUND AND AIMS: Dual antiplatelet therapy (DAPT) de-escalation strategies improve outcomes after percutaneous coronary intervention (PCI) compared to standard DAPT. However, the potential impact of sex on the safety and efficacy of these strategies is yet to be fully investigated. METHODS: Randomized controlled trials comparing de-escalated vs standard DAPT regimens in patients without baseline indication for oral anticoagulation reporting outcomes stratified by sex were included. The co-primary endpoints were trial-defined major adverse cardiovascular events (MACE) and major bleeding. Hazard ratios (HR) with 95% confidence intervals (CI) were computed to account for different follow-up durations. A network meta-analysis including ranking of treatments was performed to explore the comparative effects of different DAPT de-escalation strategies among females and males. RESULTS: Overall, 71 272 patients from 20 trials were included, and 23.3% were female. De-escalation strategies were grouped into (1) DAPT discontinuation, by aspirin or the P2Y12 inhibitor; or (2) P2Y12 inhibitor switch or dose reduction. With DAPT discontinuation vs standard DAPT, a significant interaction between treatment effect and sex was found for both MACE (Pint = .028) and major bleeding (Pint = .015). Indeed, DAPT discontinuation reduced MACE in females (HR, 0.86; 95% CI, 0.75-0.98) but not in males (HR, 1.04; 95% CI 0.93-1.16), while reducing major bleeding in males (HR, 0.60; 95% CI, 0.44-0.82) but not in females (HR, 1.04; 95% CI, 0.76-1.43), compared to standard DAPT. Conversely, no interactions by sex were found with P2Y12 inhibitor switch or dose reduction vs standard DAPT for both MACE (Pint = .668) and major bleeding (Pint = .858). At treatment ranking, aspirin discontinuation ranked best for most outcomes in females, while P2Y12 inhibitor switch to clopidogrel showed the best outcomes in males. CONCLUSIONS: Sex may influence the safety and efficacy of antiplatelet de-escalation strategies after PCI, particularly those involving the shortening of DAPT. Aspirin discontinuation may represent the optimal strategy for females, while P2Y12 inhibitor switch to clopidogrel may be most effective for males.

IMPORTANCE: Intensive blood pressure (BP) control is effective in reducing major cardiovascular events. However, whether the reduction of systolic BP may lead to kidney injury remains controversial. OBJECTIVE: To elucidate the association of intensive BP control with kidney and cardiovascular outcomes in individuals with hypertension without chronic kidney disease. DESIGN, SETTING, AND PARTICIPANTS: This study is a secondary analysis of the China Rural Hypertension Control Project (CRHCP), an open-label, blind-end-point cluster randomized trial conducted from May 8, 2018, to March 15, 2023, in 326 villages in China. Patients with a baseline estimated glomerular filtration rate (eGFR) of 60 mL/min/1.73 m2 or greater were randomized to an intervention or usual care group, stratified according to eGFR level. EXPOSURES: A nonphysician community health care professional implemented a multifaceted intervention program after training to achieve a BP treatment goal of less than 130/80 mm Hg. MAIN OUTCOMES AND MEASURES: Kidney outcome was defined as an eGFR decrease of 30% to a rate less than 60 mL/min/1.73 m2. Composite cardiovascular outcomes included cardiovascular death, stroke, myocardial infarction, and heart failure. RESULTS: A total of 33 332 patients with a baseline eGFR of 60 mL/min/1.73 m2 or greater were included in this subgroup analysis (mean [SD] age, 62.8 [9.1] years; 61.3% female). After 36 months of follow-up, in 7562 participants with eGFRs between 60 and 90 mL/min/1.73 m2, 121 participants in the intervention group and 101 in the usual care group (risk ratio, 1.17; 95% CI, 0.82-1.62; P = .36) experienced kidney outcome, which was not statistically significant. As for cardiovascular outcomes, 210 participants (2.0% per year) in the intervention group and 346 participants (3.3% per year) in the usual care group had the composite cardiovascular disease outcome, and the disparity between the 2 groups was statistically significant (hazard ratio, 0.57; 95% CI, 0.47-0.68; P < .001). CONCLUSIONS AND RELEVANCE: This secondary analysis of the CRHCP study suggests that intensive BP control was associated with reduced incidence of the composite cardiovascular disease outcome but not increased risk of kidney injury in patients without chronic kidney disease. These findings provide further evidence supporting the implementation of intensive BP control in patients without chronic kidney disease. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03527719.

BACKGROUND AND AIMS: Infective endocarditis (IE) after mitral valve (MV) interventions is a serious complication. However, information on the long-term risk of first-time IE after MV replacement or repair is lacking. The 10-year incidence of first-time IE was examined in patients undergoing MV replacement or repair, compared with those at moderate risk of IE. METHODS: Using Danish nationwide registries (2000-2020), the study population included patients undergoing isolated MV replacement or repair and patients at moderate risk of IE. The moderate-risk group included cardiac implantable electronic devices, congenital heart valve anomalies, hypertrophic cardiomyopathy, rheumatic heart diseases, and non-rheumatic degenerative valve diseases. The Aalen-Johansen estimator and cause-specific Cox regression models were used to determine the 10-year comparative incidences of IE. RESULTS: The study population included 1220 patients undergoing MV replacement, 3239 undergoing MV repair, and 209 517 at moderate risk of IE. The 10-year cumulative incidences of IE were 6.1% [95% confidence interval (CI) 4.8%-7.7%] for MV replacement, 1.6% (95% CI 1.1%-2.1%) for MV repair, and 1.7% (95% CI 1.6%-1.7%) for the moderate-risk group. Compared with the moderate-risk group, after multivariable adjustment, MV replacement was associated with a higher 10-year IE rate (hazard ratio 3.52, 95% CI 2.73-4.52), whereas MV repair was not associated with IE (hazard ratio 0.76, 95% CI 0.56-1.04). CONCLUSIONS: In this nationwide study, MV replacement was associated with a 3.5-fold increased 10-year IE rate, whereas MV repair was not significantly associated with IE, compared with patients at moderate risk of IE. These findings highlight the need for further investigation into preventive measures, including targeted antibiotic prophylaxis.