More than 15 million Americans have coronary heart disease and most should be taking aspirin daily. Given aspirin’s ubiquity in cardiovascular medicine and patients’ pill boxes, it is shocking that there are still so many unanswered questions about aspirin use. Which dose and dosage forms should be prescribed? How common is aspirin resistance? What is the relationship between platelet inhibition and clinical outcomes?
Many patients with atrial fibrillation (AF) received triple antithrombotic therapy after undergoing a percutaneous coronary intervention (PCI) and receiving cardiac stent. Triple therapy consists of warfarin plus dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor and low-dose aspirin. But is triple therapy the best approach? This practice, while widely employed, is not entirely evidence-based. Moreover, the effectiveness and safety of the direct oral anticoagulants (DOACs) in this patient population is unknown.
Approximately one in three patients with diabetes in the United States have chronic kidney disease (CKD). The Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes (EMPA-REG OUTCOME) trial, published in 2015, demonstrated a reduction in cardiovascular and all-cause mortality in patients treated with empagliflozin. More recent data from the EMPA-REG OUTCOME trial suggests that empagliflozin may also confer significant renal protection.
The HOPE-3 trial sought to determine if blood pressure (BP) and cholesterol-lowering therapies are effective and safe as primary prevention strategies in intermediate risk patients. The American College of Cardiology and American Heart Association (ACC/AHA) guidelines support a risk-based approach to statin use but in intermediate risk patients the tradeoffs between benefit and risk were deemed “less clear.” Do the results of HOPE-3 trial provide enough evidence to support routinely treating intermediate risk patients?
According to the current (2016) ADA guidelines, no agent is “the preferred” second line therapy after metformin monotherapy — instead the benefits, risks, cost, and convenience of each option should be considered and treatment should be individualized. The liraglutide and cardiovascular outcomes in type 2 diabetes (LEADER) trial, which assessed the long-term cardiovascular effects of liraglutide, a GLP-1 receptor agonist, comes at an interesting time shortly after the publication of the empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes (EMPA-REG OUTCOME) trial. Both studies found a cardiovascular benefit. How, then, will the results of these trials affect the algorithm for type 2 diabetes management and more importantly, clinical practice?
Resistant hypertension (RH) is frequently encountered in primary care practice and often presents a significant clinical challenge because limited evidence-based guidance exists. RH is a major cause of cardiovascular disease and death, and has been associated with a 50% increased risk of myocardial infarction, stroke, congestive heart failure, and chronic kidney disease when compared to patients without RH. The American Heart Association defines RH as uncontrolled BP despite maximal treatment with a three-drug regimen, ideally including a diuretic. The exact prevalence of RH is unknown, but large randomized controlled trials suggest it affects one in five patients with elevated BP. Previous research findings suggest chlorthalidone, spironolactone, and eplerenone are all effective add-on therapies when BP remains uncontrolled with typical first line agents. The Pathway-2 study provides the first direct comparative evaluation of three different four-drug antihypertensive regimens.
Could a nutritional supplement be the “magic bullet” in heart failure therapy? Coenzyme Q10 (CoQ10), or ubiquinone, is an electron carrier in mitochondria and plays a key role in ATP synthesis. It is also thought to have antioxidant effects and may stabilize LDL molecules. All of which would, theoretically, help the failing heart.
After cardiovascular (CV) safety concerns emerged with rosiglitazone use, the Food and Drug Administration (FDA) now requires outcome studies to be performed for all new diabetes medications. The first CV safety study (ELIXA) for a drug in the glucagon-like peptide 1-receptor agonist (GLP-1 RA) class – lixisenatide - was published in December 2015. Lixisenatide is a once-daily injectable GLP-1 RA approved for use in Europe and awaits FDA approval in the United States.
The recommended treatment duration for a first episode of unprovoked venous thromboembolism (VTE) is, at a minimum, 3 months with extended anticoagulation favored for those who are not at high risk for bleeding. However, the optimal duration of anticoagulation therapy remains unknown.
The Prolonged Anticoagulation Treatment for a First Episode of Idiopathic Pulmonary Embolism (PADIS-PE) study examines this question but, most importantly, provides insights about patient outcomes after anticoagulation treatment is discontinued
Two new mAbs, alirocumab and evolocumab, have been approved to treat elevated cholesterol when added to maximally tolerated statin therapy in patients with familial hypercholesterolemia or history of atherosclerotic cardiovascular disease (ASCVD). This new class of drugs, the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, is considered to be the biggest breakthrough in cholesterol treatment since statins were approved 3 decades ago. But are they worth it?