Daily Cardiology Research Analysis

BACKGROUND: In randomized trials, finerenone, a nonsteroidal mineralocorticoid receptor antagonist, improved kidney and cardiovascular outcomes in patients with type 2 diabetes and chronic kidney disease (CKD). Whether finerenone has similar effects in patients without diabetes who have CKD is unknown. METHODS: We randomly assigned adults without diabetes who had CKD (estimated glomerular filtration rate [eGFR], 25 to <90 ml per minute per 1.73 m RESULTS: A total of 1584 participants underwent randomization - 793 were assigned to the finerenone group, and 791 to the placebo group. The mean (±SD) baseline eGFR was 46.8±16.2 ml per minute per 1.73 m CONCLUSIONS: Among adults with CKD who did not have diabetes, finerenone led to a slower decrease in the eGFR than placebo over 32 months. (Funded by Bayer; FIND-CKD ClinicalTrials.gov number, NCT05047263.).

BACKGROUND AND AIMS: After percutaneous coronary intervention (PCI), growing evidence supports P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy (DAPT) as a safer and equally effective antiplatelet strategy compared with continued DAPT. However, the optimal timing of aspirin discontinuation remains uncertain. METHODS: A systematic review and meta-analysis of randomized controlled trials investigating different timings of aspirin discontinuation after a short course of DAPT in PCI patients, compared with continued DAPT, was conducted. Pairwise random-effects and network meta-analyses were performed. The primary endpoint was major adverse cardiovascular events (MACE). Secondary endpoints included major bleeding, major or minor bleeding, net adverse cardiovascular events (NACE), all-cause death and myocardial infarction. The study was registered in PROSPERO (CRD420251140207). RESULTS: Eleven randomized trials including 37,443 patients were identified. In pairwise analyses, compared with 12-month DAPT, there were no significant differences in the risk of MACE with aspirin discontinuation at either ≤1 month (risk ratio [RR] 1.01; 95% confidence interval [CI] 0.85-1.20) or 3 months (RR 0.95; 95% CI 0.67-1.36), with no significant differences between discontinuation timings. Both major and major or minor bleeding were significantly reduced with ≤1-month (RR 0.46; 95% CI 0.23-0.94; P = 0.038 and RR 0.43; 95% CI 0.36-0.51; P < 0.001, respectively) and 3-month (RR 0.59; 95% CI 0.39-0.89; P = 0.027 and RR 0.57; 95% CI 0.53-0.60; P = 0.005, respectively) discontinuation, with a more pronounced reduction in major or minor bleeding with ≤1-month discontinuation (P = 0.044 for interaction). NACE was significantly reduced with ≤1-month discontinuation, and no significant differences between discontinuation timings emerged. Network meta-analyses yielded consistent results, and for major or minor bleeding, the indirect comparison showed superiority of ≤1-month over 3-month aspirin discontinuation (RR, 0.75; 95% CI, 0.57-0.99; P = 0.044). In a sensitivity analysis restricted to acute coronary syndromes, early aspirin discontinuation was associated with a higher risk of stent thrombosis (RR 1.81; 95% CI 1.15-2.84; P = 0.019), with the excess risk observed mainly with very early aspirin discontinuation (<1 month). CONCLUSIONS: Aspirin discontinuation at either ≤1 or 3 months with continued P2Y12 inhibitor monotherapy is associated with similar MACE, lower bleeding, and lower NACE compared with continued DAPT. Discontinuation within the first month may confer additional bleeding benefit, but at the cost of excess stent thrombosis, particularly in patients at higher ischaemic risk.

BACKGROUND AND AIMS: The 2021 ESC guidelines on cardiovascular (CV) disease prevention recommend the SMART-REACH lifetime risk model to guide treatment decisions in patients with established atherosclerotic CV disease. The aim was to develop the SMART-REACH2 model for estimating lifetime risk of recurrent CV events and treatment benefits in patients with established atherosclerotic CV disease, with systematic recalibration to the four European and other global risk regions. METHODS: SMART-REACH2 was derived in 8708 individuals aged 40-90 years with coronary, cerebrovascular, peripheral artery disease and/or abdominal aortic aneurysm from the UCC-SMART cohort. Sex-stratified, cause-specific Cox models for recurrent CV events and non-CV death were fitted using age as timescale and routinely available predictors. Recurrent CV events were defined as a composite of myocardial infarction, stroke, or CV death. Recalibration was based on representative cohorts per risk region. External validation was performed in 2 085 780 patients from 54 countries; model performance was assessed by calibration plots and Harrell's C-statistic. RESULTS: In the derivation cohort, 2057 recurrent CV events occurred over a median follow-up of 8.5 years (25th-75th: 4.3-13.0). In external validation, 307 706 events occurred. The pooled C-statistic was 0.68 (95% confidence interval 0.66-0.69) and ranged from 0.66 (0.64-0.69) for European low-risk region up to 0.72 (0.66-0.78) for Latin America, with adequate calibration across risk regions. Performance was consistent across sexes and CV disease subtypes. Using SMART-REACH2, estimated potential gains in CV disease-free life expectancy for a 50-year-old example patient receiving intensified preventive treatment (15 mmHg systolic blood pressure and 1.0 mmol/L low-density lipoprotein cholesterol reduction) ranged from 2 years in the low-risk region to 4.4 years in the very-high-risk region. CONCLUSIONS: The updated SMART-REACH2 model accounts for geographical and sex-specific variations and allows estimation of short-term and lifetime risk of recurrent CV events and treatment benefits, facilitating shared decision-making as recommended by guidelines.