In this PACUPod AI-powered overview, we review a prospective, propensity-score matched cohort examining whether initiating dapagliflozin during hospitalization for acute myocardial infarction reduces malignant ventricular arrhythmias and improves survival in elderly patients. From the ChangZhou Registry, the study reports 2.2% malignant ventricular arrhythmias with dapagliflozin versus 5.1% in controls, with significant odds reductions after matching and lower all-cause mortality at a median follow-up of about seven months. We discuss clinical implications, mechanistic rationale, and limitations of a single-center observational design, along with future directions for multicenter randomized trials. Context is provided by prior SGLT2 inhibitor evidence (DAPA-HF, DAPA-MI) and relevant meta-analyses.

{

"episode_description": "In this PACULit daily literature update, we review Liu and colleagues' pragmatic, cluster-randomized trial evaluating AI-enabled ECG alerts to identify atrial fibrillation and boost initiation of oral anticoagulants (NOACs) among non-cardiology hospitalists in two Taiwanese centers. The AI analyzes standard 12-lead ECGs and notifies physicians when AF risk is high, providing actionable recommendations to diagnose AF and start anticoagulation. Primary outcomes were NOAC prescription within 90 days of discharge, new AF diagnosis, echocardiogram orders, and cardiology referrals; secondary outcomes included ischemic stroke, cardiovascular death, and all-cause mortality. Results showed higher NOAC initiation (23.3% vs 12.0%; HR 1.85) and more new AF diagnoses (HR 1.40) in the AI arm, with no significant differences in stroke or death during follow-up. The open-label design and real-world, two-hospital setting highlight practical considerations for integrating AI into hospital workflows, potential alert fatigue, and the multidisciplinary collaboration needed to ensure safe anticoagulation, including pharmacist involvement and attention to drug interactions and dosing in the elderly or renally impaired. The study builds on prior AI AF detection work (Attia, Hannun) and underscores the need for longer-term studies to assess hard clinical outcomes while moving toward broader adoption of AI-assisted AF screening and stroke prevention.",

"keywords": [

"AI-enabled ECG",

"atrial fibrillation",

"NOAC",

"oral anticoagulants",

"anticoagulation initiation",

"AF detection",

PACULit Daily Literature Update: Antiplatelet Therapy in Myocardial Bridge — Insights From the RIALTO Registry

Join Britany and Seth as they unpack the RIALTO registry, a multi-center ambispective study evaluating single antiplatelet therapy at discharge versus no antiplatelet therapy in patients with myocardial bridge (MB) who lack other indications for antiplatelet therapy. Over a median follow-up of 4.5 years, single antiplatelet therapy was associated with a higher rate of net adverse clinical events (NACE), driven primarily by minor bleeding, with no significant reduction in ischemic events. The discussion covers the pathophysiology of MB (ischemia largely due to systolic compression rather than plaque rupture), why aspirin may not confer ischemic protection in this setting, and the implications for clinical practice and guidelines. The episode situates RIALTO within the broader evidence landscape, including the ADAPTT study and prior reviews, and candidly addresses study limitations such as residual confounding and the observational design. Practical takeaways emphasize individualized risk assessment, shared decision-making, and careful medication review to mitigate bleeding risks. The team also explores alternative management strategies (e.g., beta-blockers, calcium channel blockers), diagnostic tools (IVUS, OCT), and functional testing to tailor therapy. The conversation underscores the need for randomized trials to confirm these findings and guide future management of MB-related ischemia.

PACULit Daily Literature Update examines the PRAGUE-25 trial comparing catheter ablation to lifestyle modification plus guideline-directed antiarrhythmic drugs in obese adults with atrial fibrillation. This prospective, randomized, multicenter noninferiority study enrolled 212 participants with BMI 30–40 and followed them for about 23.5 months. The primary endpoint was freedom from AF at 12 months (no episodes >30 seconds on a 7‑day Holter). Results show catheter ablation achieved significantly higher rhythm control at 12 months (73% vs 34.6%, p<0.001) despite greater weight loss and HbA1c improvements in the lifestyle-plus-drug group. The episode discusses the clinical implications: ablation provides more robust rhythm suppression in higher BMI ranges, while lifestyle changes meaningfully improve metabolic health. Strengths include objective rhythm monitoring and multicenter design; limitations include the 12-month primary endpoint and generalizability restricted to patients without severe comorbidities or prior ablation. Context is provided with LEGACY and ARREST-AF findings, emphasizing a nuanced, patient-centered approach: ablation may be preferred for rhythm control in obesity, but lifestyle interventions remain vital for cardiovascular risk reduction and metabolic health. View the full PRAGUE-25 publication in JACC for deeper insights and apply these findings to practice with individualized patient discussions about risks, expectations, and long-term management.

{

"episode_title": "PACULit Daily Literature Update: Risk of Acute Infections in New Users of Antihypertensive Drugs",

"episode_description": "Britany and Seth review a large UK observational cohort study (Aebi et al., J Am Heart Assoc, 2025) that compares new users of amlodipine, ramipril, and bendroflumethiazide, focusing on acute outpatient infections and SARS-CoV-2 infection during 2020–2021. The study reports that amlodipine users have lower infection incidence than ramipril or bendroflumethiazide, and a notable reduction in diagnosed COVID-19. The discussion covers potential immunomodulatory mechanisms, study design and strengths (new-user design, propensity score weighting, large sample size), and limitations (observational design, residual confounding, outpatient data limitations). Clinical implications include considering potential immunomodulatory benefits when initiating antihypertensives, while emphasizing the need for randomized trials and awareness of drug interactions (CYP3A4) and comorbidities. The episode also situates these findings within the broader infection risk landscape and highlights areas for future research.",

"key_findings": [

"Amlodipine use associated with lower acute infection incidence vs ramipril (IRR 0.77) and vs bendroflumethiazide (IRR 0.78).",

"Infections ranged 38.9 per 1,000 person-years with amlodipine vs 51.6 per 1,000 with bendroflumethiazide.",

"During 2020–2021, amlodipine linked to a 43% lower risk of diagnosed SARS-CoV-2 infection (IRR 0.57)."

],

"limitations": [

"Observational design with potential residual confounding despite propensity score weighting.",

"Outcomes based on outpatient records; possible underreporting or misclassification.",

"Causality cannot be established without randomized trials."

],

"clinical_implications": [

"Amlodipine may offer immunomodulatory benefits beyond blood pressure control when initiating antihypertensive therapy.",

"Clinicians should weigh infection risk profiles and monitor for drug interactions (e.g., CYP3A4-mediated interactions with amlodipine).",

"Further randomized trials are needed to confirm causality and assess infection severity and outcomes."

],

"callouts": [

"Study used UK CPRD data from 2000 to 2021 in new monotherapy users without prior cardiovascular disease.",

"Primary comparisons: amlodipine vs ramipril; amlodipine vs bendroflumethiazide.",

"Findings include infection risk during the COVID-19 era, offering unique insights into infection susceptibility."

],

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.