What’s Hot in Clots – May 2024

Key Updates in Thrombosis

Table of Contents

1. Beta-blockers after MI for all patients? Not quite – and maybe true for many other scenarios!
2. Diltiazem and the risk of bleeding from apixaban and rivaroxaban
3. Long-term add-on ticagrelor in patients with diabetes and PAD?
4. Pregnancy and COVID-19: How high are the risks of thrombotic and cardiovascular outcomes?

There is warmer weather, and we are in the midst of a fruitful NATF Board meeting. And sadly, there is also lots of unrest and disputes around the world. I hope and pray for constructive discourse and peace for all. Here are my suggested articles of the month:

Beta-blockers after MI for all patients? Not quite – and maybe true for many other scenarios!

For a long time, beta-blockers were considered a cornerstone of post-MI treatment. Payers set quality metrics, questioning hospitals and clinicians who did not prescribe beta-blockers for at least a year post-MI. But there was a caveat! The data to support such practice was from decades ago, when dual antiplatelet therapy, high-dose statins, and early revascularization were not standard treatment for these patients. Now in this multicenter randomized trial of patients with acute MI and left ventricular ejection fraction of at least 50% who received modern medical therapies and had early angiography (and revascularization, if needed), there was no benefit for beta-blocker therapy (versus control) for the primary outcome of death or reinfarction (hazard ratio: 0.96).

My summary here is longer than usual, in part because I find this paper thematically critically important, in addition to its valuable content. I find this to be one of the most important studies in 2024. Do we need to revisit many of the existing therapies in thrombosis medicine, cardiovascular medicine, and medicine in general if they were introduced many years ago, at a time when disease identification and/or standard of care were different? I would say yes!! Data age matters! Read more.

Diltiazem and the risk of bleeding from apixaban and rivaroxaban

Diltiazem is a popular drug for rate control in patients with atrial fibrillation who either cannot take beta-blockers or are maxed out on beta-blocker therapy. All that said, it is an inhibitor of CYP3A4 and the P-glycoprotein systems and thereby may increase the levels of drugs metabolized through those pathways. Among them are rivaroxaban and apixaban, two of the most widely used anticoagulants. In this large study, the authors raise concern for an association between use of diltiazem and excess risk with these two drugs. Is this association causal? Maybe. Would I still consider using diltiazem? Likely yes – but more cautiously. Is there an alternative? Hypothetically, edoxaban is less prone to this drug-drug interaction, but we need more high-quality evidence.  Read more.

Long-term add-on ticagrelor in patients with diabetes and PAD?

In the THEMIS trial, long-term treatment with ticagrelor (versus placebo) as an add-on to aspirin in patients with diabetes and stable coronary disease without myocardial infarction or stroke resulted in lower incidence of ischemic events at the cost of excess bleeding. Now a timely subanalysis of patients with PAD at baseline has been published, which largely shows findings similar to the main trial. The question that I have—coming from EUCLID—is whether clopidogrel will have a similar effect. And regardless, are these regimens better than very low-dose rivaroxaban as studied in COMPASS and VOYAGER? Read more.

Pregnancy and COVID-19: How high are the risks of thrombotic and cardiovascular outcomes?

Findings from a multicenter study suggest that the absolute risk is relatively low among outpatients, although certain high-risk subgroups with multiple risk factors for thrombotic events may need more careful follow-up, especially during the third trimester and early postpartum periods. Read more.

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