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This randomized trial involving patients with osteoarthritis or rheumatoid arthritis who were at increased cardiovascular risk showed the noninferiority of celecoxib to naproxen or ibuprofen with respect to cardiovascular safety. Nonsteroidal antiinflammatory drugs (NSAIDs) were introduced in the 1960s and became the most widely prescribed class of drugs in the world, with more than 100 million prescriptions issued annually in the United States alone. 1 NSAIDs inhibit cyclooxygenase (COX), which reduces pain and inflammation through the inhibition of prostaglandins. However, the COX enzyme is also present in gastric mucosa, where it stimulates gastroprotective prostaglandins. The identification of two isoforms, COX-1 and COX-2, and the recognition that antiinflammatory and analgesic effects are mediated through COX-2 inhibition — whereas the gastrointestinal toxic effects are linked to COX-1 inhibition — resulted in the development . . .

In a randomized trial involving patients with high-risk vascular disease, the cholesteryl ester transfer protein inhibitor evacetrapib had favorable effects on established lipid biomarkers but was not associated with a lower rate of cardiovascular events than placebo. Pharmacologic reduction of the low-density lipoprotein (LDL) cholesterol level with statins substantially decreases the risks of death and complications from cardiovascular causes. 1 , 2 Considerable interest has focused on the identification of approaches that might further reduce cardiovascular-event rates among high-risk patients. 3 Epidemiologic studies have shown inverse associations between high-density lipoprotein (HDL) cholesterol levels and cardiovascular outcomes, 4 – 6 a correlation that persists despite treatment with statins. 7 Nevertheless, therapeutic interventions that raise the HDL cholesterol level have not been shown to reduce cardiovascular risk. Cholesteryl ester transfer protein (CETP) modulates the transfer of esterified cholesterol from HDL to apolipoprotein B–containing lipoproteins. 8 Two . . .

Early revascularization is the mainstay of treatment for cardiogenic shock (CS) complicating acute myocardial infarction. However, data on the contemporary trends in management and outcomes of CS complicating non–ST-elevation myocardial infarction (NSTEMI) are limited. We used the 2006 to 2012 Nationwide Inpatient Sample databases to identify patients aged ≥18 years with NSTEMI with or without CS. Temporal trends and differences in coronary angiography, revascularization, and outcomes were analyzed. Of 2,191,772 patients with NSTEMI, 53,800 (2.5%) had a diagnosis of CS. From 2006 to 2012, coronary angiography rates increased from 53.6% to 60.4% in patients with NSTEMI with CS (ptrend <0.001). Among patients who underwent coronary angiography, revascularization rates were significantly higher in patients with CS versus without CS (72.5% vs 62.6%, p <0.001). Patients with NSTEMI with CS had significantly higher risk-adjusted in-hospital mortality (odds ratio 10.09, 95% confidence interval 9.88 to 10.32) as compared to those without CS. In patients with CS, an invasive strategy was associated with lower risk-adjusted in-hospital mortality (odds ratio 0.43, 95% confidence interval 0.42 to 0.45). Risk-adjusted in-hospital mortality, length of stay, and total hospital costs decreased over the study period in patients with and without CS (ptrend <0.001). In conclusion, we observed an increasing trend in coronary angiography and decreasing trend in in-hospital mortality, length of stay, and total hospital costs in patients with NSTEMI with and without CS. Despite these positive trends, overall coronary angiography and revascularization rates remain less than optimal and in-hospital mortality unacceptably high in patients with NSTEMI and CS.

Current data regarding gender disparities in outcomes after acute pulmonary embolism (PE) are limited and controversial. We sought to assess the gender-specific rates and trends in treatment, outcomes, and complications after acute PE. We used the 2003 to 2011 Nationwide Inpatient Sample database for this analysis. All hospital admissions with a principal diagnosis of acute PE were identified using the International Classification of Diseases, Ninth Edition, codes. Inhospital mortality and discharge to nursing facility were co-primary outcomes of our study. Secondary outcomes included shock, transfusion of blood products, utilization of thrombolysis, inferior vena cava filter placement, and cost of hospitalization. Over a 9-year period, a total of 276,484 discharges with acute PE were identified. Compared with men, there was significantly higher inhospital mortality in women admitted with acute PE (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.03 to 1.15). In addition, there was a significantly higher need for discharge to nursing facility among women compared with men (OR 1.30, 95% CI 1.27 to 1.34). Besides this, women experienced a higher need for transfusion (OR 1.38, 95% CI 1.33 to 1.44) and occurrence of shock (OR 1.10, 95% CI 1.01 to 1.18) during hospitalization. Furthermore, there was a significantly lower utilization of vena cava filters (OR 0.86, 95% CI 0.84 to 0.89) in women compared with men. Among patients in shock who were eligible for thrombolysis (age <75 years, no previous stroke, no bleeding on presentation, and not pregnant), the utilization of thrombolysis was similar between men and women (OR 1.19, 95% CI 0.93 to 1.53). Lastly, the cost of hospitalization after acute PE was significantly higher in men than women (adjusted mean difference $425, 95% CI $304 to $546). In conclusion, among patients admitted with acute PE, women tend to have more adverse outcomes and higher incidence of complications compared with men.

We aimed to evaluate the secular trends in demographics, risk factors, and clinical characteristics of patients presenting with acute myocardial infarction (AMI) or acute ischemic stroke (AIS), using a large nationally representative data set of in-hospital admissions. We used the 2003 to 2013 Nationwide Inpatient Sample. All admissions with primary diagnosis of AMI or AIS were included. Across 2003 to 2013, a total of 1,360,660 patients with AMI and 937,425 patients with AIS were included in the study. We noted a progressive reduction in the mean age of patients presenting with AMI and AIS (p trend <0.001 for all groups), implying that the burden of young patients with these acute syndromes is progressively increasing. In addition, there was a progressive increase in the proportion of patients who are uninsured among patients presenting with AMI and AIS. Furthermore, despite a progressively younger age at presentation, there was an observed increase in the prevalence of atherosclerotic risk factors including hypertension, hyperlipidemia, diabetes, smoking, and obesity among patients presenting with AMI or AIS during 2003 to 2013. Significant disparities were noted in the prevalence of risk factors among various demographic and geographical cohorts. Low socioeconomic status as well as uninsured patients had a significantly higher prevalence of preventable risk factors like smoking and obesity as compared to the high socioeconomic status and insured patients, respectively. In conclusion, there have been significant changes in the risk factor profile of patients presenting with AMI and AIS over the last decade.

[...]data on differences in outcomes of AM patients with and without COVID-19 infection is limited. [...]we performed this study to ascertain: 1) the incidence of AM in patients with COVID-19; and 2) the outcomes of COVID-19 versus non-COVID-19 hospitalized AM patients. [...]the findings of our study are alarming as around 1/3rd of the COVID-19 patients hospitalized with AM died. [...]COVID-19 AM patients had more than three times the higher likelihood of adjusted mortality. [...]this is the largest cohort of COVID-19 AM patients demonstrating significantly increased mortality in COVID-19 AM patients in the pre-vaccination period.Prior presentation None.Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.CRediT authorship contribution statement Agam Bansal: Conceptualization, Data curation, Writing – original draft.

ObjectivesThe CHA2DS2-VASc score is the preferred risk model for anticoagulation decision-making in atrial fibrillation (AF) patients. Recent studies have found this score to have prognostic value in other cardiovascular diseases. We assessed the relationships between CHA2DS2-VASc score and long-term mortality in adults referred for stress testing,Methods165 184 consecutive patients from January 1991 to December 2014 from a prospective registry were studied, with CHA2DS2-VASc score calculated for all patients, and AF and anticoagulation status were recorded. The primary endpoint was all-cause mortality.ResultsIn this cohort, 12 450 (7.5%) patients had AF and mean CHA2DS2-VASc score was 2.2±1.2. There were 22 152 (18.4%) deaths during mean follow-up of 6.1±4.8 years. In multivariable analysis, CHA2DS2-VASc score, presence of AF and anticoagulation use, along with end-stage renal failure and smoking were all independently associated with mortality with HRs (95% CIs) of 1.23 (1.21 to 1.25), 1.18 (1.10 to 1.27) and 1.50 (1.40 to 1.60), respectively. Higher CHA2DS2-VASc score was incrementally associated with worse survival both in patients with and without AF (log-rank p<0.001). Anticoagulation use was associated with reduced survival in non-AF patients with alternative anticoagulation indications at all CHA2DS2-VASc score categories, and AF patients with lower CHA2DS2-VASc score 0–2, but was protective in AF patients with higher CHA2DS2-VASc score 4–9.ConclusionIncrementally higher CHA2DS2-VASc score, a simple clinical tool, is associated with mortality in patients regardless of presence of AF and anticoagulation status. Anticoagulation use was associated with worse survival in non-AF patients and AF patients with low CHA2DS2-VASc scores, but was protective in AF patients with high CHA2DS2-VASc scores.

Glycated hemoglobin (HbA1c) is an approved and widely used laboratory investigation for diagnosis of diabetes that is not affected by acute changes in blood glucose. Our aim was to analyze the extent to which routine HbA1c measurements diagnose unknown diabetes mellitus (DM) in patients presenting with ST-segment elevation myocardial infarction (STEMI). We also compared outcomes in patients with newly diagnosed DM, previously established DM and those without DM. Consecutive patients undergoing PCI for STEMI from January 2005 to December 2012 were included and routinely performed admission HbA1c was used to identify patients with previously undiagnosed DM (HbA1c ≥6.5 and no history of DM or DM therapy) and pre-DM (HbA1c 5.7% to 6.4%). Overall 1,686 consecutive patients underwent primary percutaneous coronary intervention for STEMI during the study period and follow-up data were available for 1,566 patients (90%). A quarter of the patients (24%, n = 405) had history of DM, 7% (n = 118) had previously undiagnosed DM, and 38.7% (n = 652) had pre-DM. Mortality was comparable in patients with known DM and newly diagnosed DM both in-hospital (11.1% vs 11.9%, p = 0.87) and at 3-year follow-up (27.3% and 24%). Patients with DM, including those who were newly diagnosed, had higher mortality at 3 years (26.5%) compared to those with pre-DM (12.1%) or no dysglycemia (11.2%, p <0.01). In conclusion, a substantial number of patients with STEMI have previously undiagnosed DM (7%). These patients have similar in-hospital and long-term mortality as those with known DM, and outcomes are inferior to patients without dysglycemia.

Ischemic mitral regurgitation (IMR) has been associated with worse outcome myocardial infarction. However, severity of mitral regurgitation (MR) and its impact on patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) remains unknown. We sought to determine impact of increasing severity of IMR on outcomes in patients with STEMI undergoing primary PCI. All patients presenting with STEMI who underwent primary PCI within 12 hours of symptoms from 1994 to 2014 were included. IMR was graded from 0 to 4+ within 3 days of index myocardial infarction by echocardiography. Overall, 4,005 patients with STEMI were included. None, 1+, 2+, 3+, and 4+ MR were present in 3,200 (79.9%), 427 (10.7%), 260 (6.5%), 91 (2.3%), and 27 (0.7%) patients, respectively. On multivariate logistic regression analysis, more severe MR was associated with older age, female gender, lower body mass index, anemia, inferior STEMI, and longer door-to-balloon time. The 30-day mortality rates were 6.8%, 7.3%, 8.8%, 19.8%, and 26.1%, respectively, with increasing grade of MR. The 1-year mortality rates were 10.8%, 12.4%, 20.8%, 37.4%, and 37.1%, whereas 5-year mortality rates were 16.2%, 23.1%, 36.5%, 53.8%, and 63%, respectively (p <0.001 all), for none to 4+ MR. After adjusting for age, gender, co-morbidities, ejection fraction, and shock by multivariate analysis, severity of IMR was associated with incremental effect on long-term mortality (hazard ratios of 1.42, 1.83, 2.41, and 2.95 for 1+ to 4+ MR respectively, p <0.01 for all). In conclusion, higher grades of MR in patients with STEMI undergoing primary PCI are associated with worse short- and long-term outcomes.