The combination of oral anticoagulation with a P2Y₁₂ inhibitor and aspirin in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is associated with a high bleeding risk. Dual antithrombotic therapy (DAT) with omission of aspirin is a promising option to reduce bleedings, but carries a yet unknown risk of ischemic events. We therefore sought to systematically review and analyse randomized controlled trials investigating DAT versus triple antithrombotic therapy (TAT) in patients with AF following PCI and/or acute coronary syndrome (ACS). We included 4 trials with overall 9317 patients (5039 DAT, 4278 TAT) in our analysis. DAT was associated with a significant reduction in thrombolysis in myocardial infarction (TIMI) major bleeding (HR 0.52 [95% CI 0.42 – 0.65]; p = 0.0001), while the composite trial-defined ischemic endpoint did not differ significantly between DAT and TAT (HR 0.98 [95% CI 0.79 – 1.22]; p = 0.88). There was also no difference regarding the occurrence of myocardial infarction (MI; HR 1.16 [95% CI 0.92 – 1.46]; p = 0.21) or stent thrombosis (HR 1.25 [95% CI 0.69 – 2.26]; p = 0.46). Absolute numbers for MI were 131/4278 (3.1%) with TAT and 182/5039 (3.6%) with DAT, and for stent thrombosis 32/4278 (0.75%) and 52/5039 (1%), respectively. A post-hoc power calculation based on the size and event rate of this meta-analysis revealed 80% power to detect a 37% and 100% increase in MI and stent thrombosis, respectively. DAT significantly reduces bleedings compared to TAT and seems to have a similar effect in preventing ischemic endpoints in AF patients post PCI or ACS. Future investigations are needed to determine its applicability specifically in patients with high risk of ischemic outcomes.

Coronavirus disease-19 (COVID-19) emerged late December 2019 in the city of Wuhan, China and has since spread rapidly all over the world causing a global pandemic. While the respiratory system is the primary target of disease manifestation, COVID-19 has been shown to also affect several other organs, making it a rather complex, multi-system disease. As such, cardiovascular involvement has been a topic of discussion since the beginning of the COVID-19 pandemic, primarily due to early reports of excessive myocardial injury in these patients. Treating physicians are faced with multiple challenges in the management and early triage of patients with COVID-19, as disease severity is highly variable ranging from an asymptomatic infection to critical cases rapidly deteriorating to intensive care treatment or even fatality. Laboratory biomarkers provide important prognostic information which can guide decision making in the emergency department, especially in patients with atypical presentations. Several cardiac biomarkers, most notably high-sensitive cardiac troponin (hs-cTn) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), have emerged as valuable predictors of prognosis in patients with COVID-19. The purpose of this review was to offer a concise summary on prognostic cardiac biomarkers in COVID-19 and discuss whether routine measurements of these biomarkers are warranted upon hospital admission.

The effective and fast reduction of circulating low-density lipoprotein cholesterol (LDL-C) is a cornerstone for secondary prevention of atherosclerotic disease progression. Despite the substantial lipid-lowering effects of the established treatment option with statins and ezetimibe, a significant proportion of very-high-risk patients with cardiovascular disease do not reach the recommended treatment goal of <55 mg/dL (<1.4 mmol/L). Novel lipid-lowering agents, including the proprotein convertase subtilisin/kexin type 9 (PCSK9) antibodies alirocumab and evolocumab, the small interfering ribonucleotide acid (si-RNA) inclisiran, as well as the recently approved bempedoic acid, now complete the current arsenal of LDL-C lowering agents. These innovative therapies have demonstrated promising results in clinical studies. Besides a strong reduction of LDL-C by use of highly effective agents, there is still discussion as to whether a very rapid achievement of the treatment goal should be a new strategic approach in lipid-lowering therapy. In this review, we summarize evidence for the lipid-modifying properties of these novel agents and their safety profiles, and discuss their potential pleiotropic effects beyond LDL-C reduction (if any) as well as their effects on clinical endpoints as cardiovascular mortality. In addition to a treatment strategy of “the lower, the better”, we also discuss the concept of “the earlier, the better”, which may also add to the early clinical benefit of large LDL-C reduction after an acute ischemic event.

Rationale: Preserved ratio impaired spirometry (PRISm) is a recently recognized spirometric pattern defined by a ratio of forced expiratory volume in 1 second to forced vital capacity of at least 0.70 and a forced expiratory volume in 1 second <80% of reference. For unclear reasons, PRISm is associated with increased cardiovascular (CV) morbidity and mortality. Arterial stiffness is a major mechanism of CV disease, which can be measured by carotid-femoral pulse-wave velocity (cfPWV). Objectives: We explored the hypothesis that cfPWV would be increased in individuals with PRISm and airflow limitation (AL). Methods: We measured forced spirometry, lung volumes by body plethysmography, and cfPWV in 9,466 subjects recruited from the general population in the Austrian cross-sectional LEAD (Lung, Heart, Social, Body) study and tested the association of arterial stiffness with PRISm and AL by multivariable linear regression analysis. Individuals younger than 18 years were excluded from the study. Results: Individuals with PRISm (n = 431; 4.6%) were of similar age to those with normal spirometry (n = 8,136; 85.9%) and significantly younger than those with AL (n = 899; 9.5%). Arterial hypertension, diabetes mellitus, coronary artery disease, heart failure, and peripheral arterial occlusive disease were significantly more common in individuals with PRISm than in those with normal lung function and similar to those with AL. There was a significant association between PRISm and arterial stiffness on bivariate linear regression analysis (crude model, β = 0.038; 95% confidence interval [CI], 0.016–0.058), which persisted after robust adjustment for clinical confounders upon multivariable analysis (final model, β = 0.017; 95% CI, 0.001–0.032). cfPWV was significantly higher in individuals with PRISm irrespective of the presence of established CV disease or pulmonary restriction. AL also showed a significant association with arterial stiffness on multivariable linear regression analysis (final model, β = 0.025; 95% CI, 0.009–0.042). Conclusions: Arterial stiffness measured by cfPWV is increased in individuals with PRISm independent of CV disease and risk factors. The pathobiological mechanisms underlying this association deserve further research.

Background: Non-bacterial thrombotic endocarditis (NBTE) is a rare condition, usually observed in association with malignancy, lupus erythematosus, or antiphospholipid syndrome. Diagnosis of NBTE remains a challenge as patients are often asymptomatic up to their first thromboembolic event. While there is no randomized data available for the guidance of treatment in NBTE, effective anticoagulation remains the main focus in the management of affected patients. Case summary: A 44-year-old female patient without a significant medical history presented to the emergency department with a new numbness of her right hand. Magnetic resonance imaging scans facilitated the diagnosis of supratentorial stroke. Within the next 3 months, the patient had multiple thromboembolic events, including multiple strokes, pulmonary embolism, and renal/splenic infarction. Echocardiographic examination revealed large, transient vegetations of the aortic valve with concomitant aortic regurgitation. In addition, an incidental, pulmonary non-small-cell adenocarcinoma was found during the diagnostic work-up. Infective endocarditis was excluded by several negative blood cultures and missing signs of infection. Hence, the diagnosis of NBTE secondary to malignancy was made. Discussion: We present a rare case of NBTE in the context of pulmonary adenocarcinoma. The adequate treatment of malignancy and effective anticoagulation are the main treatment options.