PACUPod: Cardiology

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.

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 PACUPod episode reviews a secondary analysis of the SUMMIT trial investigating how baseline adiposity (BMI and central adiposity via waist-height ratio) and weight loss influence tirzepatide's benefits in obesity-related HFpEF. The discussion covers study design, primary outcome (time to cardiovascular death or worsening heart failure), and secondary outcomes (KCCQ-CSS, six-minute walk distance, CRP, body weight, and systolic blood pressure). Tirzepatide reduced the primary endpoint across all BMI and WHR tertiles, while improvements in functional and inflammatory markers varied with adiposity. Central adiposity identified higher-risk subgroups beyond BMI, and greater weight loss correlated with better 6MWD, quality of life, and reductions in CRP and SBP, suggesting weight loss mediates several benefits. The episode also discusses clinical implications, including targeting central adiposity, dosing considerations, potential pharmacologic interactions, and the need for longer-term data. Future directions include imaging studies to assess remodeling, combination therapy with other HFpEF agents, patient-reported outcomes, precision medicine for responder phenotyping, and cost-effectiveness analyses.

A concise overview of a prospective controlled cohort study assessing whether adding low-dose colchicine (0.5 mg daily) to stable vitamin K antagonist (VKA) therapy in adults with chronic coronary disease affects anticoagulation control. Primary outcome: INR changes; secondary outcomes: VKA dose adjustments and time in therapeutic range (TTR). Findings: initiation, continuation, or withdrawal of low-dose colchicine did not significantly alter INR, VKA dosing, or TTR, supporting safe coadministration without additional INR monitoring beyond standard care. Limitations include short follow-up, exclusion of unstable disease and severe renal/hepatic impairment, and lack of formal safety assessment for bleeding or thrombosis. Clinical implications: aligns with existing guidelines and suggests simpler anticoagulation management when colchicine is added in stable patients, though vigilance during early use and consideration of polypharmacy remain important. Future research: longer-term studies and evaluation in special populations, including those with renal impairment or on multiple interacting drugs.

This PACUPod episode reviews Wu et al.'s randomized trial in JAMA Network Open evaluating early cardiac rehabilitation initiated during the CICU for patients with acute decompensated heart failure. In this single-center study of 120 high-risk CICU patients, participants were randomized to an early, progressive, personalized cardiac rehab program during CICU stay (AHF-CR) or to usual care without structured early rehab. Primary outcomes were discharge Short Physical Performance Battery (SPPB) score and six-month all-cause rehospitalization; exploratory outcome included the Perme ICU Mobility score during the CICU stay. Results showed no significant difference in discharge SPPB (median difference 1.0 point; 95% CI crossed zero; p=0.16) or six-month rehospitalization (26.6% vs 28.3%). The rehab group did exhibit improved mobility in the CICU (Perme score median difference 2.76; adjusted p=0.04) and there were no safety concerns. The findings suggest early CICU mobilization is feasible and safe, but restricting rehab to the CICU without post-discharge continuation did not improve discharge function or reduce readmissions. Context with prior rehab literature indicates longer, outpatient or integrated rehab programs (e.g., REHAB-HF) may yield larger functional and clinical benefits, while meta-analyses (Imrpress 2023) show benefits with earlier exercise-based rehab when extended beyond ICU. The episode highlights the importance of rehab timing, duration, and continuity after discharge, as well as multidisciplinary coordination to optimize outcomes for ADHF patients.

PACULit examines the SOGALDI-PEF trial, the first randomized crossover study comparing dapagliflozin alone versus dapagliflozin plus spironolactone in heart failure with preserved or mildly reduced ejection fraction (HFpEF/HFmrEF). The episode discusses the rationale for combining an SGLT2 inhibitor with a mineralocorticoid receptor antagonist, the primary NT-proBNP endpoint as a surrogate for cardiac stress, and key results showing an approximate 11% relative reduction in NT-proBNP with combination therapy, along with reductions in systolic blood pressure and urinary albumin-to-creatinine ratio, but with greater eGFR decline and higher potassium-related safety concerns. Design features (108 patients, 12-week treatment periods per arm, open-label with blinded endpoints) and limitations (short duration, small sample, lack of hard outcomes) are explored, as are clinical implications for balancing potential efficacy with risks of hyperkalemia and renal dysfunction. The episode emphasizes the need for careful patient selection, monitoring, and larger, longer trials to confirm hard outcomes in HFpEF/HFmrEF.

PACULit daily literature update: This episode reviews the 2025 study by Houwen et al. in the European Journal of Clinical Pharmacology, which evaluates the impact of low‑dose colchicine (0.5 mg daily) on coagulation in adults with stable chronic coronary disease on vitamin K antagonists. In a prospective controlled cohort, initiation, continuation, or withdrawal of colchicine did not significantly alter INR, VKA dosing, or time in therapeutic range, suggesting minimal clinically relevant interaction and no need for extra INR monitoring beyond standard care in this population. We discuss the study design, primary and secondary outcomes, and the clinical implications for anticoagulation management, including alignment with current guidelines and the study’s limitations—short follow‑up, exclusion of unstable disease and severe organ impairment, and absence of formal safety endpoints. The episode also situates findings within the broader colchicine literature (LoDoCo2, NLRP3 inflammasome involvement) and highlights areas for future research, such as interactions with other anticoagulants, special populations, and real‑world polypharmacy. Practical takeaways for clinicians and pharmacists: maintain standard INR monitoring, monitor during initial Weeks of therapy, and perform thorough medication reconciliation to manage potential drug interactions.