The edition · Cardiology
Anticoagulation beat no treatment at intermediate stroke risk in atrial fibrillation
SINGLE-AF gives the class IIa recommendation its first randomised support, though on few events. Also: statins in the over-70s, ultrashort DAPT after ACS, scar-guided ICDs, and anticoagulation after TAVI.
The edition in brief
In SINGLE-AF, 1803 Korean patients with atrial fibrillation and a CHA2DS2-VASc score of 1 (men) or 2 (women) were randomised to a DOAC or no anticoagulation. At 24 months the composite of stroke, systemic embolism, major bleeding or cardiovascular death was 0.5% versus 1.5% (HR 0.31), with similar major bleeding. STAREE randomised 9971 Australians aged 70 or over without cardiovascular disease, diabetes or dementia to atorvastatin 40 mg or placebo: major cardiovascular events fell (HR 0.70) but disability-free survival did not change. A meta-analysis of 10 trials in 29,232 ACS patients found DAPT of one month or less halved major bleeding without an overall rise in ischaemic events, but a week or less, or clopidogrel or aspirin monotherapy, raised MACCE. CMR GUIDE found no reduction in sudden death or significant ventricular arrhythmia from an ICD in patients with LVEF 36–50% and myocardial scar. ACASA-TAVI found DOAC monotherapy after TAVI reduced leaflet thrombosis on CT against aspirin and was non-inferior on a bleeding, thromboembolism and death composite. Today's pearl: recalculate CHA2DS2-VASc at every review, because an intermediate score does not stay intermediate.
Atorvastatin in over-70s cut cardiovascular events but did not extend disability-free survival
Offer atorvastatin to healthy over-70s to prevent vascular events, and tell them plainly it did not extend disability-free survival.
Ultrashort DAPT after ACS halves bleeding — if the monotherapy is a potent P2Y12 inhibitor
If you shorten DAPT after ACS PCI, keep it for at least two weeks and follow with ticagrelor or prasugrel, especially after STEMI.
Scar on CMR did not justify an ICD when LVEF was 36–50%
Do not implant primary prevention ICDs on the strength of CMR scar alone when LVEF is 36–50%.
DOAC monotherapy after TAVI reduced leaflet thrombosis against aspirin
Keep aspirin as the default after TAVI, but DOAC monotherapy is now a reasonable option to discuss for selected younger, low-bleeding-risk patients.
Recalculate CHA2DS2-VASc at every review
Recalculate CHA2DS2-VASc at every review and after every admission; an old score is a common reason for missed anticoagulation.
DOACs reduced events at intermediate stroke risk in atrial fibrillation
Offer a DOAC to patients with atrial fibrillation at intermediate stroke risk, explaining that the absolute benefit is about one event per 100 over two years.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for cardiology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free