Edoxaban VS Dual Antiplatelet Therapy for Valve Thrombosis
A study investigated the effect of Edoxaban compared to DAPT for the prevention of leaflet thrombosis. It was found that the incidence of leaflet thrombosis on CT scans was less frequent with Edoxaban therapy, although did not reach statistical significance. The incidence of new cerebral thromboembolism and neurological or neurocognitive dysfunction were not different between two groups.
New Agents to Lower Triglycerides-rich Lipoproteins
Angiopoietin like protein 3 (ANGPTL3) is a protein expressed in the liver inhibiting LPL and endothelial lipase activity thereby increasing TG, LDL-C and HDL. An ECLIPSE trial studied monoclonal antibody, Evinacumab that targets ANGPTL3. It was found that the Evinacumab decreases LDL-C by 47% and TG by 50%. ANGPTL3 and Apoprotein C III inhibition are promising therapies for hypertriglyceridemia.
Effects of Short-interfering RNA Targeting Lipoprotein(a)
Elevated Lipoprotein(a) is associated with atherosclerotic cardiovascular disease (ASCVD) & aortic stenosis (AS). APOLLO trial found that subcutaneous injection of an siRNA (SLN360) targeting mRNA for LPA gene lowered lipoprotein(a) upto 98%. >70% and >80% reductions in Lp(a) persisted for 150 days after the 300 mg and 600 mg doses. The highest doses reduced LDL-C and Apo-B by 20-30%.
Patiromer For The Management Of Hyperkalemia
DIAMOND trial included patients with HFrEF and hyperkalemia where they were optimized on RAASi therapy including MRA & patiromer. Patiromer showed significantly lesser increase in serum K+ levels than placebo (+0.03 vs +0.13). Patiromer had lesser no. of hyperkalemia events than placebo (61 vs 85). Lesser no. of patients with patiromer had reduction of MRA dose below target (61 vs 83).
Effects of Alirocumab on Coronary Atherosclerosis
A study determined early administration of PCSK9i alirocumab in patients with acute myocardial infarction (AMI). Compared to placebo, Alirocumab resulted in greater decrease in Percent Atheroma Volume (IVUS) (-2.1 vs -0.9, P=0.001). After 52 weeks of treatment, Alirocumab on top of high-intensity statin therapy reducted lipid burden and increased minimal fibrous cap thickness.
Guidelines for Hypertension Management : ESC/ESH Perspective
Treatment strategy for uncomplicated hypertension is dual combination initial therapy of ACEi or ARB plus CCB or diuretic in 1 pill. Step 2 of therapy will be triple combination of ACEi or ARB plus CCB plus diuretic in single pill. If hypertension is still resistant, spironolactone or other diuretic, alpha-blocker or beta-blocker is added to the triple combination therapy with 2 pills.
Novel and Emerging Therapies: Bempedoic Acid
CLEAR study showed that Bempedoic acid significantly reduced LDL-C level as compared to placebo. Also, combination of Bemepedoic acid and ezetimibe decreases LDL-C and hsCRP level by 35%. FDA 2020 has approved Bemepedoic acid and Bemepedoic acid plus ezetimibein for the treatment of heterozygous familial hypercholesterolemia (HeFH) or established atherosclerotic cardiovascular disease (ASCVD).
Novel and Emerging Therapies: Inclisiran
Phase I trial of the PCSK9 inhibitor Inclisiran 300 mg showed that LDL-C could be reduced ~50% with twice yearly injections for 4-6 months. Two doses of Inclisiran lowered LDL-C for upto 6 months. In ORION-10 study, Inclisiran showed significant reduction in LDL-C by 58% after 17 months of treatment. Also, Inclisiran had similar safety and tolerability compared with placebo.
Dietary Management of Lipid Disorders in Youth
Most lipid disorders in children are associated with obesity. For LDL-C disorders, mediations will likely be needed but a diet lower in saturated fat and higher in fiber can assist. For triglyceride disorders, medications are less likely to achieve optimal goals and focused nutrition and physical activity is a mainstay. Fruits, vegetables, & whole grains should be included in the diet.
Management of Dyslipidemia During Reproductive Years
Women with familial hypercholesterolemia have high LDL-C level during pregnancy than non-FH women. FH management during pregnancy is considered with healthy lifestyle and stop statins, ezemtimibe, niacin, fibrates, PCSK9i 4 weeks prior to discontinuing contraception. Bile acid sequestrants are only acceptable medication. Lipoprotein apheresis is also considered safe for very high risk women.
SODIUM-HF: Dietary Intervention Under 100 Mmol in HF
SODIUM-HF trial aimed to investigate the effects of a low-sodium diet, compared to usual care in HF patients at the end of 12 months. Patients in the low sodium group had greater chance of improvement in NYHA class with the OR of 0.59. There was statistically significant difference between low sodium diet group and usual care in terms of KCCQ scores (quality of life).
How Should We Treat Large Thrombus Burden in 2022?
As per ACC/AHA guidelines, class III indication is for routine thrombus aspiration and class II b indication for bailout or selective aspiration. In a study, thrombectomy reduced rate of CV death compared to percutaneous coronary intervention. In patients with high thrombus burden, routine TIA was associated with lower CV death. CAT RX technology can provide satisfactory results in thrombectomy.
Combining Antiplatelets & Anticoagulants in Atrial Fibrillation Patients
Stroke prevention is recommended in atrial fibrillation patients with >1 non-sex CHA2DS2-VASc stroke factor (score of >1 in males or >2 in females). For patients with 1 non-sex stroke factor, oral anti-coagulants should be considered. An early internal carotid artery should be considered in patients at risk for high bleeding, irrespective of anti-coagulant exposure.
New Key Recommendations for Antithrombotic Treatment
In atrial fibrillation patients, after a short period of triple antithrombotic therapy, double antithrombotic therapy is recommended as the default strategy for stroke prevention and single oral antiplatelet agent (preferably clopidogrel). Double antithrombotic therapy may be considered as an alternative to triple antithrombotic therapy in patients with a moderate to high risk of stent thrombosis.
Antithrombotic Management in Atrial Fibrillation Patients
In AF patients with thromboembolism risk, new oral anticoagulants should be preferred over vitamin K antagonists. Aspirin should be used up to one week post PCI and up to one month in case of high thrombotic risk and acceptable bleeding risk. A combination of new oral anticoagulant plus oral P2Y12 inhibitor with aspirin use limited to the peri-PCI period should be the default strategy.
Triglycerides as a Factor in Residual ASCVD Risk
To treat patients with high TG and to lower ASCVD risk, always encourage diet and lifestyle first, manage diabetes (with Pioglitazone, SGLT2I, GLP1-RA), obesity, high BP. Statins are first-line in essentially all patients. If the TG is still >135 mg/dL fasting (or >150 non-fasting), add IPE, if possible, Rx DAW/brand only, generic IPE not indicated to decrease ASCVD or for TG
Pharmacotherapy For Weight Management
Newer agents introduced for weight management includes Phentermine/Topiramate, Buproprion/Naltrexone XR, Liraglutide, CelIulose/Citric acid, and Semaglutide. Studies have shown that semaglutide causes a significant reduction in body weight as compared to placebo over a period of 68 weeks and was able to achieve >20% of weight loss in comparison to placebo.
QOL Tool to Examine Fatigue in Subjects With DM
Norfolk QOL Tool analyses cognitive, physical, & emotional elements of fatigue. It is a 35-item self-administered questionnaire and responses graded 0-4 with higher scores indicating higher degree of fatigue symptom or functional limitation. In this tool, diabetic individuals were found to be more fatigued than healthy individuals and younger individuals reported the worst fatigue scores.
Indications for SGLT2i in Non-Diabetes Patients
Collaboration with non-endocrinologists regarding use of SGLT2Inhibitors:Understand each patient's indications for SGLT2I use; When titrating SGLT2i up or down, keep in mind the impact on numerous disease states; Collaboration using protocols, formularies, and patient specific cases; Co-management and communication
Management of Obesity Post Bariatric Surgery
Weight regain and insufficient weight loss after bariatric surgery is commonly caused by hormonal, nutritional or genetic factors. Anti-Obesity Medications (AOM) are used for WR & IR. The best time to start AOM appears to be when you reach your postsurgical nadir weight OR when you reach aweight plateau, and post-operative bariatric patients who were given two or more AOM lost more weight.
