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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸2️⃣0️⃣ Early AVR for asymptomatic severe AS: fewer HF hospitalizations and strokes, similar mortality, and a strategy worth considering for improving patient outcomes.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣9️⃣ The findings offer a framework for shared decision-making: reducing stroke and hospitalization vs. delaying AVR to avoid procedural risks in asymptomatic severe AS.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣8️⃣ Limitations include lack of patient-level data, differences in AVR modalities (SAVR vs. TAVR), and variability in study populations, highlighting areas for future research.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣7️⃣ Long-term follow-up is needed to assess reintervention rates due to valve durability, especially in younger patients, balancing early benefits with lifetime management.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣6️⃣ Guideline changes may emerge as more data highlight reduced hospitalizations and stroke risks with early AVR, supporting timely intervention for severe AS.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣5️⃣ Meta-analysis provides evidence for patient-centric benefits of early AVR, emphasizing quality of life rather than extending survival in asymptomatic severe AS.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣4️⃣ Current findings challenge assumptions about “watchful waiting” for asymptomatic severe AS, favoring earlier treatment to reduce HF hospitalization and stroke risks.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣3️⃣ Procedural stroke rates for modern TAVR platforms remain low (1-2%). Combined with stroke reductions in AVR arms, this supports early intervention's safety profile.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣2️⃣ TAVR trials showed shorter delays to AVR in CS arms (e.g., 32 days in EARLY TAVR), likely minimizing exposure to high-risk symptomatic periods and impacting mortality outcomes.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣1️⃣ Early AVR enables stable intervention, avoiding risks associated with emergency procedures during acute decompensation. This proactive strategy is key for asymptomatic patients.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸🔟 Differences in survival benefit likely relate to delays in AVR in CS groups, particularly in surgical trials where time from symptoms to AVR exceeded 4 months.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸9️⃣ Subgroup analyses showed SAVR trials (RECOVERY, AVATAR) suggested a survival benefit over CS, unlike TAVR trials (EARLY TAVR, EVoLVeD), reflecting different populations and approaches.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸8️⃣ Mortality findings showed moderate heterogeneity (I²: 61% for all-cause mortality, 50% for cardiovascular mortality), highlighting variations across trials and populations.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸7️⃣ Stroke reduction may stem from AVR’s role in reducing thromboembolic risk, subclinical atrial fibrillation, or valve-associated events—common in untreated severe AS.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸6️⃣ Hospitalization reductions with early AVR likely reflect relief of pressure overload on the left ventricle, preventing progression to symptomatic or decompensated states.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸5️⃣ This meta-analysis pooled data from 4 RCTs, including 1,427 patients (719 early AVR, 708 CS) with a follow-up of 4.1 years on average. A robust dataset supports its conclusions.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸4️⃣ Cardiovascular mortality also showed no significant difference (5.1% vs. 8.3%, HR: 0.67; 95% CI: 0.35-1.29). Lack of mortality benefit may relate to patient selection, timing, and competing risks in older populations.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸3️⃣ No significant difference in all-cause mortality between early AVR and CS (9.7% vs. 13.7%, HR: 0.68; 95% CI: 0.40-1.17). Mortality outcomes suggest AVR doesn’t necessarily extend life but improves other critical health outcomes.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸2️⃣ Stroke risk was also lower with early AVR: 4.5% vs. 7.2% (HR: 0.62; 95% CI: 0.40-0.97). The findings underscore how AVR may mitigate valve-related thromboembolic risks and structural cardiac damage over time.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣ Early aortic valve replacement (AVR) significantly reduced unplanned cardiovascular or HF hospitalizations vs. clinical surveillance (CS): 14.6% vs. 31.9% (HR: 0.40; 95% CI: 0.30-0.53). This highlights the impact of proactive intervention in asymptomatic severe aortic stenosis (AS).

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

Aortic Valve Replacement vs Clinical Surveillance in Asymptomatic Severe Aortic Stenosis: A Systematic Review and Meta-Analysis: @jaccjournals.bsky.social 🥸Early TAVR led to less unplanned CV or HF hospitalization and stroke: @PhilGenereuxMD 😱 Summary 👇👇👇

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸Two meta-analyses for older adults undergoing revascularization: 😱NSTEMI: ahajournals.org/doi/epub/10.... 😱 STEMI: agsjournals.onlinelibrary.wiley.com/doi/epdf/10.... 🥸We had a great journal club at American Geriatric Society with Dr Michael Nana on revacdularization in older adults

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸2️⃣0️⃣ Results support clopidogrel as an effective and safer alternative to aspirin for long-term secondary prevention in PCI patients.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣9️⃣ Sensitivity analyses confirmed findings with balanced baseline characteristics and consistent treatment effects.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣8️⃣ Clopidogrel reduced thrombotic and bleeding risks without significant interaction by HBR or PCI complexity, reinforcing its consistency.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣7️⃣ No significant differences in all-cause mortality between clopidogrel and aspirin were observed in any subgroup.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣6️⃣ Subgroup analyses revealed numerical thrombotic benefits of clopidogrel in complex PCI and HBR groups, despite limited power.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣5️⃣ Analysis addresses gaps in evidence for chronic antiplatelet therapy, particularly in high-risk post-PCI populations.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣4️⃣ Findings highlight clopidogrel’s sustained efficacy and safety over a median follow-up of 5.9 years.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣3️⃣ The study’s focus on an East Asian population may limit generalizability but provides strong evidence for stabilized post-PCI patients.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣2️⃣ Clopidogrel’s benefits align with recent evidence favoring P2Y12 inhibitors for long-term maintenance over aspirin post-PCI.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣1️⃣ Subgroup analysis of 4 distinct groups (HBR/non-HBR, complex/non-complex PCI) confirmed clopidogrel’s risk reduction across all combinations.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸🔟 Clopidogrel showed consistent thrombotic risk reduction across all subgroups, with no significant treatment interactions.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸9️⃣ Although bleeding reductions with clopidogrel were observed in HBR and complex PCI groups, they were not statistically significant.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸8️⃣ Clopidogrel demonstrated the greatest thrombotic risk reduction in patients with both HBR and complex PCI: HR 0.46.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸7️⃣ Complex PCI patients exhibited similar long-term thrombotic risk to non-complex PCI patients, contrary to early post-PCI patterns.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸6️⃣ Patients with HBR had higher overall thrombotic and bleeding risks compared to non-HBR patients, consistent with prior studies.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸5️⃣ Combined thrombotic and bleeding risks were lower with clopidogrel vs aspirin, regardless of HBR status or PCI complexity.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸4️⃣ This analysis included patients event-free for 6-18 months on DAPT post-PCI, with follow-up extending up to 5.9 years.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸3️⃣ Bleeding risk was consistently lower with clopidogrel: HR 0.82 (HBR), HR 0.58 (non-HBR), HR 0.79 (complex PCI), and HR 0.68 (non-complex PCI).

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸2️⃣ Among complex PCI patients, clopidogrel showed stronger thrombotic risk reduction (HR 0.49) vs aspirin (HR 0.74), though interaction by complexity was not significant (P=0.12).

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

🥸1️⃣ In a study of 3,974 stabilized post-PCI patients, clopidogrel monotherapy reduced thrombotic event risk vs aspirin: HR 0.75 (HBR) & HR 0.62 (non-HBR), with no significant interaction (P=0.38).

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 08/12/2024

Long-Term Aspirin vs Clopidogrel After Coronary Stenting by Bleeding Risk and Procedural Complexity: @jama.com cardiology 🥸Clopidogrel monotherapy in HOST-EXAM for patients with high bleeding risk or complex PCI 😱 Summary 👇👇👇

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 30/11/2024

🥸2️⃣0️⃣ Final Takeaway: New ischemia thresholds and improvements in microvascular function six months after valve replacement highlight the dynamic impact of treatment on coronary physiology in aortic stenosis.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 30/11/2024

🥸1️⃣9️⃣ Research Needs: Further randomized trials are required to evaluate coronary revascularization strategies in patients with aortic valve stenosis and coronary artery disease.

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Abdulla A. Damluji, MD, PhD, MBA @drdamluji.bsky.social · 30/11/2024

🥸1️⃣8️⃣ Key Finding: Fractional flow reserve of 0.83 or lower is a reliable threshold for identifying ischemic lesions in aortic stenosis when there is discordance with resting full-cycle ratio.

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