This PACULit update summarizes a single-center, prospective observational study (ChangZhou Registry) evaluating whether initiating dapagliflozin during hospitalization for acute myocardial infarction reduces malignant ventricular arrhythmias in elderly patients and affects all-cause mortality over about seven months. In 2,607 patients aged 60 and older with confirmed AMI, those treated with dapagliflozin were compared to standard care using propensity score matching. The primary outcome was malignant ventricular arrhythmias during hospitalization; the secondary outcome was all-cause mortality (median ~211 days). Results showed malignant ventricular arrhythmias occurred in 2.2% of the dapagliflozin group versus 5.1% in controls, with odds ratios around 0.34 after matching (roughly 60–65% risk reduction). All-cause mortality was also significantly lower in the dapagliflozin group (p = 0.033). The discussion highlights potential mechanisms for antiarrhythmic effects, including improved myocardial metabolism, reduced fibrosis, ion-channel modulation, and attenuated sympathetic activity. Limitations include its single-center, observational design and potential residual confounding, limiting generalizability. The findings suggest potential benefits of early post-AMI dapagliflozin initiation in elderly patients at high arrhythmia risk and align with broader SGLT2 inhibitor cardiovascular effects, while underscoring the need for multicenter randomized trials focused on malignant ventricular arrhythmias.

This PACULit episode reviews a large observational cohort study by Aebi et al. using UK CPRD data (2000–2021) to compare new monotherapy users of amlodipine, ramipril, and bendroflūmethylthiazide (bendroflumethiazide) and to assess risk of acute outpatient infections (respiratory, genitourinary, gastrointestinal, sepsis) and SARS-CoV-2 infection during 2020–2021. The primary comparisons were amlodipine versus ramipril and amlodipine versus bendroflumethiazide, with follow-up from prescription start to infection, censoring, or study end. Propensity score weighting balanced baseline covariates, and the study excluded individuals with prior cardiovascular disease to reduce confounding. Findings showed lower infection incidence among amlodipine users (IRR 0.77 vs ramipril; 0.78 vs bendroflumethiazide; infections per 1,000 person-years: 38.9 vs 51.6). During the COVID-19 period, amlodipine was associated with a 43% reduced risk of diagnosed SARS-CoV-2 infection (IRR 0.57). The discussion notes potential immunomodulatory and anti-inflammatory mechanisms, cites in vitro and endothelial studies, and acknowledges limitations inherent to observational designs (residual confounding, potential misclassification, and lack of randomized causality). Implications suggest considering possible infection-related benefits when initiating antihypertensive therapy, while emphasizing the need for randomized trials to confirm causality and assess broader outcomes.

A concise episode summarizing a post hoc analysis of the STEP trial that investigates how baseline cardiovascular risk modifies the balance of benefits and harms of intensive blood pressure control in older hypertensive adults. We cover study design, key findings (overall reduction in cardiovascular events with intensive targets, modest non-significant rise in adverse events), risk-stratified results, practical targets (110–130 mm Hg vs 130–150 mm Hg), and implications for practice in acute, critical, and chronic care—with emphasis on individualized therapy and vigilant monitoring.

In this PACUPod episode, we review a pragmatic, cluster-randomized trial evaluating AI-assisted interpretation of standard 12-lead ECGs to identify atrial fibrillation and prompt guideline-directed oral anticoagulant therapy in hospitalized patients managed by non-cardiologists across two Taiwanese hospitals. The AI sends alerts with actionable recommendations to consider AF diagnosis and initiate NOACs. Primary outcomes include NOAC prescription within 90 days post-discharge, new AF diagnoses, echocardiography orders, and cardiologist referrals; secondary outcomes cover ischemic stroke, cardiovascular death, and all-cause mortality. Results show a significant increase in NOAC initiation (23.3% vs 12.0%; HR 1.85) and new AF diagnoses (HR 1.40) in the AI-alert group, with no significant differences in imaging or referrals or short-term clinical outcomes. The episode discusses the implications for real-world hospital workflows, the potential to close the AF treatment gap, and the need for longer follow-up, while situating findings within prior AI AF detection research and emphasizing multidisciplinary collaboration to optimize stroke prevention through timely anticoagulation.

This PACULit episode reviews a phase 3, randomized, open-label multicenter trial evaluating edoxaban started within three months after surgical bioprosthetic valve replacement (aortic and/or mitral) compared with warfarin. The primary outcome was stroke or systemic embolism; edoxaban showed 0.5% vs 1.5% in warfarin with a risk difference of −1.03% (95% CI −4.34% to 1.95%), indicating comparable efficacy. Major bleeding was higher with edoxaban (4.1% vs 1.0%; risk difference 3.07%, 95% CI −0.67% to 7.27%). Intracardiac thrombus occurred only with warfarin (1.0%), while none were observed with edoxaban. Dosing adjustments were based on renal function and weight; edoxaban offers fixed dosing without routine INR monitoring and is a substrate of P-glycoprotein. Limitations include open-label design, short follow-up, and low event rates. Implications emphasize patient-specific thrombotic risk, valve position, and bleeding risk when choosing between DOACs and VKAs post-bioprosthetic valve surgery, with considerations of cost and adherence. Related analyses and ongoing data suggest DOACs may be viable alternatives, warranting individualized assessment.

In this PACUPod episode, the study by Augustine et al. on pharmacist-led transitions of care (TOC) after hospitalization for acute myocardial infarction (AMI) is examined. The real-world, single-center pre-post design compares outcomes before and after implementing a TOC service focused on medication reconciliation, patient education, and discharge optimization. The primary outcome was 90-day cardiovascular readmissions; secondary outcomes included 30-day cardiovascular and all-cause readmissions and discharge on defect-free guideline-directed medical therapy (GDMT). Results showed no significant reduction in 90-day cardiovascular readmissions (10.7% pre-TOC vs 9.9% post-TOC; OR 0.937, p=0.842). However, discharge on defect-free GDMT improved markedly from 61.5% to 87.7% (OR 5.424, p<0.001), highlighting a substantial process improvement even when short-term clinical outcomes did not change. Limitations include lack of randomization, use of historical controls, and absence of confounding adjustments, which limit generalizability. The episode discusses the implications of improved GDMT adherence, the essential role of medication reconciliation and patient education in TOC, and the need for outpatient follow-up and adherence monitoring to translate process gains into long-term clinical benefits. Looking ahead, the evidence suggests the value of larger multicenter randomized trials that incorporate outpatient adherence and patient-reported outcomes to better define the impact on readmissions and cardiovascular health.