BackgroundDual antiplatelet therapy is the standard of care after coronary stent placement but increases the bleeding risk. The effects of proton pump inhibitors (PPIs) on clopidogrel metabolism have been described, but the clinical significance is not yet definitive. We aimed to do an updated meta-analysis comparing outcomes in patients receiving clopidogrel with and without PPIs.MethodsWe systematically searched PubMed, Scopus and the Cochrane Central Register of Controlled Trials for randomised controlled trials (RCTs) and controlled observational studies in patients taking clopidogrel stratified by concomitant PPI use. Heterogeneity was examined with the Cochran Q test and I2 statistics; p values inferior to 0.10 and I2 >25% were considered significant for heterogeneity.ResultsWe included 39 studies with a total of 214 851 patients, of whom 73 731 (34.3%) received the combination of clopidogrel and a PPI. In pooled analysis, all-cause mortality, myocardial infarction, stent thrombosis and cerebrovascular accidents were more common in patients receiving both drugs. However, among 23 552 patients from eight RCTs and propensity-matched studies, there were no significant differences in mortality or ischaemic events between groups. The use of PPIs in patients taking clopidogrel was associated with a significant reduction in the risk of gastrointestinal bleeding.ConclusionsThe results of our meta-analysis suggest that PPIs are a marker of increased cardiovascular risk in patients taking clopidogrel, rather than a direct cause of worse outcomes. The pharmacodynamic interaction between PPIs and clopidogrel most likely has no clinical significance. Furthermore, PPIs have the potential to decrease gastrointestinal bleeding in clopidogrel users.

In this real-life study, 32% of patients received an inappropriate dose of DOAC. Several clinical factors can identify patients at risk of this situation.

Obesity is a well-known risk factor for atrial fibrillation (AF) and heart failure (HF). Epicardial fat, the true visceral fat depot of the heart, has been associated with changes in both cardiac function and morphology. In this study, we evaluated whether ultrasound-measured epicardial fat thickness is related to AF and HF. A cross-sectional study was performed in 84 consecutive subjects with clinical and ECG-documented history of permanent (AF) or paroxysmal AF (PAF) who underwent echocardiographic epicardial fat thickness measurement. Sixty-four subjects had AF and 20 showed PAF. AF subjects had higher prevalence of heart failure (HF), defined by ejection fraction (EF)<50%, (p<0.01). Subjects with AF had higher epicardial fat thickness than PAF subjects (4.8±2.5 vs. 3.5±2.4 mm, p<0.05). As subjects were stratified by HF, epicardial fat thickness was lower (4.4±2.2 vs. 5.4±2.3 mm, p<0.05) in those with HF as compared to subjects without HF. This study showed for the first time that echocardiographic epicardial fat thickness is significantly higher in subjects with chronic AF when compared to those with PAF. It is plausible that permanent AF is related to long-term influence of epicardial fat. Epicardial fat reduction in HF subjects may reflect the overall fat mass reduction, commonly observed in these patients. It is also possible to hypothesize that epicardial fat pad may incur in fibrotic changes during chronic cardiac failure.

Due to recurrent right ventricular outflow tract (RVOT) dysfunction, patients with complex congenital heart disease of the RVOT traditionally require multiple surgical interventions during their lifetimes. Percutaneous pulmonary valve implantation (PPVI) has been developed as a nonsurgical alternative for the treatment of right ventricular to pulmonary artery stenosis or pulmonary regurgitation. PPVI has been shown to be a safe and effective procedure in patients with dysfunctional surgical RVOT conduits. In this population, PPVI has the potential to improve symptoms, functional capacity, and biventricular hemodynamics. However, limitations to the anatomical substrate and size of the RVOT currently restrict PPVI eligibility to less than one-quarter of patients with RVOT dysfunction. The current review discusses contemporary practices in PPVI, evidence supporting the procedure, and future technologies and developments in the field.

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Our findings suggest that stenting of the RVOT prior to Melody valve implantation is associated with a reduction in the incidence of SF and fracture-related reinterventions.