Padma Kaul

Background: Coronary artery bypass grafting (CABG) is often preferred over percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM) and multivessel coronary artery disease (MVD), but whether it confers a long-term survival advantage remains unclear. Moreover, whether anatomic complexity modulates this relationship is unknown. Methods: We included 5,615 patients with diabetes and MVD who underwent revascularization with contemporary drug-eluting stents (PCI-DES; n=3,410) or CABG (n=2,205) in Alberta, Canada, between 2009 and 2019. The primary outcome was 5-year all-cause mortality. Secondary outcomes were 5-year major adverse cardiovascular events (MACE) and 10-year mortality and MACE in an earlier-era subcohort of 2,103 patients. Inverse probability of treatment weighting with Cox proportional hazards models was used. Interactions between revascularization, Duke Jeopardy Score (DJS), and clinical presentation (stable angina, unstable angina/NSTEMI, or STEMI) were examined. Results: Five-year all-cause mortality did not differ between PCI-DES and CABG (HR, 1.14; [95% CI,0.99-1.31]; P=0.08). However, PCI-DES was associated with a higher 5-year MACE (HR, 1.23; [95% CI,1.10-1.38]; P=0.0004), but lower 10-year all-cause mortality compared to CABG (HR,0.85; [95% CI,0.72-0.99]; P=0.04) with no difference in MACE (HR, 0.97; 95 % CI: 0.85-1.11; P=0.68). Anatomic complexity modified these findings, with lower 5-year mortality after CABG only at higher DJS (P _interaction =0.003), and lower 10-year mortality after PCI-DES only at lower DJS (P _interaction <0.0001). Conclusions: In patients with diabetes and MVD, 5-year all-cause mortality did not differ significantly between groups, although PCI-DES was associated with higher 5-year MACE rates. At 10 years, multivessel PCI-DES was associated with lower 10-year mortality and no difference in MACE. Anatomic complexity modified the effects, favouring CABG at higher DJS and PCI-DES at lower DJS. Our findings should be considered when planning revascularization in diabetes with MVD.

Background: It is unclear if sex differences exist in cognitive impairment and dementia associated with atrial fibrillation (AF) and whether this relationship is influenced by oral anticoagulation (OAC) therapy. Methods: We identified patients ≥40 years with incident non-valvular AF (NVAF) and without previous history of cognitive impairment or dementia, stroke/transient ischemic attack or contraindication to OAC between April 1st, 2012 and March 31st, 2024, using linked administrative databases in Alberta, Canada. Outcomes included cognitive impairment, Alzheimer’s disease, vascular dementia, and all-cause mortality. Survival models were used to estimate association between sex and outcomes, and between OAC therapy and outcome stratified by sex. Results: Of 66,885 patients, 43% were female. Compared to males, females were older (74 vs 68 years), frailer (14.7% vs 10.1%), and more likely to have CHA ₂ DS-VA score ≥2 (73% vs 65%). OAC was initiated in 60% of both sexes within 120 days of diagnosis. Females had a higher risk for cognitive impairment (aHR 1.14 [95% CI 1.07-1.20], p<0.0001), but a lower risk of vascular dementia (aHR 0.75 [95% CI 0.63-0.90], p=0.0016) and all-cause mortality (aHR 0.91 [95% CI 0.88-0.94], p<0.001), with no difference in risk of Alzheimer’s disease (aHR 1.01 [95% CI 0.88-1.17], p=0.8496) between the sexes. Non-vitamin-K OAC (NOAC) use was associated with a lower risk of cognitive impairment compared to either warfarin or no OAC in both sexes, but a lower risk of Alzheimer’s and vascular dementia in males only. Conclusion: In this large population-based study, we found females have a higher risk of cognitive impairment, but a lower risk of vascular dementia and all-cause mortality compared to males. For both sexes, NOAC use was associated with a lower risk of cognitive impairment compared to no OAC and a lower risk of Alzheimer’s and vascular dementia in males only.

Aim: To estimate the prevalence of medication use in nonhospitalized pregnant women with COVID‐19. Methods: A prospective two‐stage individual patient meta‐analysis across 10 data sources in Europe and North America studied medication use among nonhospitalized pregnant women with COVID‐19 between January 2020 and December 2022. Comparisons were made between medication use within 30 days pre‐ and post‐COVID‐19 diagnosis in this cohort and two comparator groups: pregnant women without COVID‐19 and nonpregnant women with COVID‐19. Prevalence estimates were pooled using a random‐effects model stratified by trimester. Results: 50 335 nonhospitalized pregnant women with COVID‐19 were identified. The pooled prevalence of antibacterial use in the third trimester was higher post‐COVID‐19 diagnosis (6.8%, 95% confidence interval [CI] = 5.5–8.4, I ² = 94%) compared with the same women pre‐COVID‐19 (3.9%, 95% CI = 3.1–4.9, I ² = 89%). Overall, pregnant women with COVID‐19 had higher medication use compared to pregnant women without COVID‐19, although the CIs of the prevalence overlapped. Post‐COVID‐19, antithrombotic prevalence was 4.5% (95% CI = 1.1–16.5, I ² = 100%) among pregnant women with COVID‐19 in the third trimester, compared to 2.1% (95% CI = 1.2–3.6, I ² = 99%) among those without COVID‐19 in the third trimester. Compared to nonpregnant women with COVID‐19, pregnant women with COVID‐19 were less likely to be prescribed analgesics, antiprotozoals, corticosteroids, psychoanaleptics and psycholeptics, and more likely to be prescribed antithrombotics, cough and cold and nasal preparations, and drugs used in diabetes across all trimesters. High heterogeneity existed in nearly all analyses. Conclusion: This international meta‐analysis reveals low medication use and country‐specific variations, enhancing insight into the management of COVID‐19 in nonhospitalized pregnant women. Higher antithrombotic use post‐COVID‐19 suggests prophylactic treatment in this population, but variation between countries emphasizes the challenges of combining multinational data.

Over 100 million pregnant people worldwide remain at risk of COVID-19. We compared the prevalence of severe COVID-19 in pregnancy and in people of reproductive age, and the risk of adverse pregnancy/neonatal outcomes in those with/without COVID-19 during gestation. In the Canadian Mother–Child Cohort, two sub-cohorts were identified using medical services, prescription medication fillings, hospitalizations, and COVID-19 surveillance testing programs data (28 February 2020–2021). The first included all pregnant people with at least one completed trimester of pregnancy during the study period, stratified on COVID-19 status. The second included all non-pregnant people (aged 15–45) with a positive COVID-19 test during the same period. COVID-19 severity was categorized based on hospital admissions before the end of pregnancy. Associations between COVID-19 during pregnancy and adverse perinatal outcomes were quantified using log-binomial regressions. A total of 150,345 pregnant people (3464 (2.3%) had COVID-19), and 112,073 non-pregnant people with COVID-19 were included. Maternal age at the time of COVID-19 diagnosis/positive test was statistically significantly lower among pregnant individuals compared to those who were not pregnant (96% had less than 40 years vs. 80%, p < 0.001). In pregnancy, COVID-19 was associated with the risk of spontaneous abortions (adjRR 1.76, 95%CI 1.37, 2.25), gestational diabetes (adjRR 1.52, 95%CI 1.18, 1.97), prematurity (adjRR 1.30, 95%CI 1.01, 1.67), and NICU (adjRR 1.32, 95%CI 1.10, 1.59); COVID-19 treatment with medications reduced risks. Severe COVID-19 was more prevalent in pregnancy and was associated with higher risks of adverse maternal/neonatal outcomes. As some countries are pulling back preventive strategies for COVID-19, this study highlights the importance of continued surveillance during pregnancy to prevent adverse pregnancy outcomes.

Pregnant women are often excluded from randomized clinical trials due to safety concerns, yet the increasing prevalence of pre-existing conditions and pregnancy complications necessitates medication use. Observational cohort data can provide valuable insights to support clinical decision-making. We developed a web-based tool that presents population-level data on medication use and preterm birth risk. By integrating real-world evidence, this tool helps clinicians assess medication-related outcomes and improve maternal and neonatal health.

Background: Coronary artery bypass grafting (CABG) has been associated with reduced mortality, myocardial infarction, and repeat revascularization compared with percutaneous coronary intervention (PCI) for patients with 3‐vessel coronary artery disease (CAD) and diabetes. The majority of previous studies have been limited to follow‐up of P =0.003, adjusted hazard ratio [aHR], 0.75 [95% CI, 0.61–0.91]), myocardial infarction (15.6% versus 28.1%, P P P =0.656) and stroke (11.6% versus 12.2%, P =0.794) did not significantly differ between groups. Conclusions: In this study, we describe one of the longest follow‐up periods for patients with diabetes and 3‐vessel coronary artery disease who underwent CABG or PCI and confirmed that the shorter‐term benefits seen in randomized trials do translate into longer‐term reductions in risk of death, myocardial infarction, or repeat revascularization.