To compare the efficacy and safety of P2Y₁₂ inhibitor or aspirin monotherapy for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD). Medline, Embase, and Cochrane Central databases were searched to identify randomized trials comparing monotherapy with a P2Y₁₂ inhibitor versus aspirin for secondary prevention in patients with ASCVD (cardiovascular, cerebrovascular, or peripheral artery disease). The primary outcome was major adverse cardiac events (MACE). Secondary outcomes were myocardial infarction (MI), stroke, all-cause mortality, and major bleeding. A random-effects model was used to calculate risk ratios (RR) and the corresponding 95% confidence interval (CI) and heterogeneity among studies was assessed using the Higgins I² value. A total of 9 eligible trials (5 with clopidogrel and 4 with ticagrelor) with 61 623 patients were included in our analyses. Monotherapy with P2Y₁₂ inhibitors significantly reduced the risk of MACE by 11% (0.89, 95% CI 0.84–0.95, I² = 0%) and MI by 19% (0.81, 95% CI 0.71–0.92, I2 = 0%) compared with aspirin monotherapy. There was no significant difference in the risk of stroke (0.85, 95% CI 0.73–1.01), or all-cause mortality (1.01, 95% CI 0.92–1.11). There was also no significant difference in the risk of major bleeding with P2Y₁₂ inhibitor monotherapy compared with aspirin (0.94, 95% CI 0.72–1.22, I² = 42.6%). Results were consistent irrespective of the P2Y₁₂ inhibitor used. P2Y₁₂ inhibitor monotherapy for secondary prevention is associated with a significant reduction in atherothrombotic events compared with aspirin alone without an increased risk of major bleeding. A meta-analysis of 9 randomized trials (61 623 patients) was conducted to compare P2Y₁₂ inhibitor monotherapy versus aspirin monotherapy for secondary prevention of cardiovascular events in patients with established atherosclerotic cardiovascular disease (coronary, cerebrovascular, or peripheral artery disease). The included studies had follow-up periods between 3 and 36 months. Monotherapy with P2Y₁₂ inhibitors (clopidogrel or ticagrelor) significantly reduced the risk of MACE by 11% (0.89, 95% CI 0.84–0.95, I² = 0%) and MI by 19% (0.81, 95% CI 0.71–0.92, I² = 0%) compared with aspirin monotherapy. There was no significant difference in the risk of stroke, all-cause mortality, or major bleeding. Subgroup analysis revealed that the reduction in MACE with P2Y₁₂ inhibitors was driven by a reduction in recurrence of the qualifying event. CI = confidence interval, P2Y12i = P2Y₁₂ inhibitor, RR = risk ratio.

Background: Prevention strategies targeting standard modifiable cardiovascular risk factors (SMuRFs; diabetes, hypertension, smoking, hypercholesterolemia) are critical to improving cardiovascular disease outcomes. However, acute myocardial infarction (AMI) among individuals who lack 1 or more SMuRFs is not uncommon. Moreover, the clinical characteristics and prognosis of SMuRFless individuals are not well characterized. Methods and Results: We analyzed AMI hospitalizations from 2000 to 2014 captured by the ARIC (Atherosclerosis Risk in Community) study community surveillance. AMI was classified by physician review using a validated algorithm. Clinical data, medications, and procedures were abstracted from the medical record. Main study outcomes included short‐ and long‐term mortality within 28 days and 1 year of AMI hospitalization. Between 2000 and 2014, a total of 742 (3.6%) of 20 569 patients with AMI were identified with no documented SMuRFs. Patients without SMuRFs were less likely to receive aspirin, nonaspirin antiplatelet therapy, or beta blockers and less often underwent angiography and revascularization. Compared with those with one or more SMuRFs, patients without SMuRFs had significantly higher 28‐day (odds ratio, 3.23 [95% CI, 1.78–5.88]) and 1‐year (hazard ratio, 2.09 [95% CI, 1.29–3.37]) adjusted mortality. When examined across 5‐year intervals from 2000 to 2014, the incidence of 28‐day mortality significantly increased for patients without SMuRFs (7% to 15% to 27%), whereas it declined for those with 1 or more SMuRFs (7% to 5% to 5%). Conclusions: Individuals without SMuRFs presenting with AMI have an increased risk of all‐cause mortality with an overall lower prescription rate for guideline‐directed medical therapy. These findings highlight the need for evidence‐based pharmacotherapy during hospitalization and the need to discover new markers and mechanisms for early risk identification in this population.

Background: Peripheral artery disease (PAD) is both a common comorbidity and a contributing factor to heart failure. Whether PAD is associated with hospitalization for recurrent decompensation among patients with established heart failure is uncertain. Methods and Results: Since 2005, the ARIC (Atherosclerosis Risk in Communities) study has conducted active surveillance of hospitalized acute decompensated heart failure (ADHF), with events verified by physician review. From 2005 to 2016, 1481 patients were hospitalized with ADHF and discharged alive (mean age, 78 years; 69% White). Of these, 207 (14%) had diagnosis of PAD. Those with PAD were more often men (55% versus 44%) and smokers (17% versus 8%), with a greater prevalence of coronary artery disease (72% versus 52%). Patients with PAD had an increased risk of at least 1 ADHF readmission, both within 30 days (11% versus 7%) and 1 year (39% versus 28%) of discharge from the index hospitalization. After adjustments, PAD was associated with twice the hazard of ADHF readmission within 30 days (HR, 2.02; 95% CI, 1.14–3.60) and a 60% higher hazard of ADHF readmission within 1 year (HR, 1.60; 95% CI, 1.25–2.05). The 1‐year hazard of ADHF readmission associated with PAD was stronger with heart failure with reduced ejection fraction (HR, 2.01; 95% CI, 1.29–3.13) than preserved ejection fraction (HR, 1.04; 95% CI, 0.69–1.56); P for interaction=0.05. Conclusions: Patients with ADHF and concomitant PAD have a higher likelihood of ADHF readmission. Strategies to prevent ADHF readmissions in this high‐risk group are warranted.

Background: Acute myocardial infarction (AMI) with in‐hospital onset (AMI‐IHO) has poor prognosis but is clinically underappreciated. Whether its occurrence has changed over time is uncertain. Methods and Results: Since 1987, the ARIC (Atherosclerosis Risk in Communities) study has conducted adjudicated surveillance of AMI hospitalizations in 4 US communities. Our analysis was limited to patients aged 35 to 74 years with symptomatic AMI. Patients with symptoms initiating after hospital arrival were considered AMI‐IHO. A total of 26 678 weighted hospitalizations (14 276 unweighted hospitalizations) for symptomatic AMI were identified from 1995 to 2014, with 1137 (4%) classified as in‐hospital onset. The population incidence rate of AMI‐IHO increased in the 4 ARIC communities from 1995 through 2004 to 2005 through 2014 (12.7—16.9 events per 100 000 people; P for 20‐year trend <0.0001), as did the proportion of AMI hospitalizations with in‐hospital onset (3.7%–6.1%; P for 20‐year trend =0.03). The 10‐year proportions were stable for patients aged 35 to 64 years (3.0%–3.4%; P for 20‐year trend =0.3) but increased for patients aged ≥65 years (4.6%–7.8%; P for 20‐year trend =0.008; P for interaction by age group =0.04). AMI‐IHO had a more severe clinical course with lower use of AMI therapies or invasive strategies and higher in‐hospital (7% versus 3%), 28‐day (19% versus 5%), and 1‐year (29% versus 12%) mortality ( P< 0.0001 for all). Conclusions: In this population‐based community surveillance, AMI‐IHO increased from 2005 to 2014, particularly among older patients. Quality initiatives to improve recognition and management of AMI‐IHO should be especially focused on hospitalized patients aged >65.

Aim: To study clinical profile of children with mediastinal tuberculosis (TB). Methods: This retrospective study was undertaken between January 2015 and March 2018 in children diagnosed with mediastinal TB. Clinical history, examination and radioimaging, such as chest X-ray and HRCT chest, were done in every patient at the start of therapy. The prevalence of mediastinal TB was calculated. Factors associated with mediastinal TB and associated pulmonary TB (PTB) were analysed. Results: Out of total 1407 patients with TB, 58 (4.12%) had mediastinal involvement. Fever was seen in 49 (84.5%) patients, positive Mantoux test (MT) in 32 (68.1%), cough in 28 (48.3%), loss of appetite in 24 (41.4%) and weight loss in 17 (29.3%). Associated PTB was present in 22 (37.9%) patients. Associated extrapulmonary TB (EPTB) was observed in 12 (20.7%) patients. Fifty-one patients (87.9%) had an abnormal X-ray. Baseline HRCT chest was done in 54 (93.1%) patients and all of them showed necrotic caseous mediastinal nodes. Treatment duration of patients who completed treatment with first-line anti-tuberculous therapy was 11.67 months. Seventeen patients (29.3%) were diagnosed to have drug-resistant TB (DR-TB). Cough was seen more commonly in patients with associated PTB (68.2%) as compared to isolated mediastinal TB (36.1%) (p = 0.0296). Conclusion: Mediastinal TB is common in children with EPTB. Associated PTB is seen in only about one-third of the patients. X-ray chest is abnormal in half the patients; hence, HRCT chest may be required to make a diagnosis. Bacteriological confirmation is necessary due to high incidence of DR-TB in these patients. Most of the patients require treatment for a longer duration as resolution takes a longer time. Computed tomography imaging on follow-up helps to determine the treatment duration.