AIMS:Left ventricular (LV) thrombus is a severe complication of acute myocardial infarction (AMI) and chronic heart failure. While current guidelines support the use of direct oral anticoagulants (DOACs) as alternatives to vitamin K antagonists (VKA), their benefit across different aetiologies remains uncertain. This study aimed to compare the efficacy and safety of DOAC vs. VKA across different aetiologies of LV dysfunction. METHODS AND RESULTS:We conducted a multi-centre observational study including 901 patients with confirmed LV thrombus treated with either a VKA or DOAC. The primary outcome was thrombus resolution, secondary outcomes included stroke and systemic embolization (SSE), major bleeding and mortality with analyses performed by aetiology. The principal aetiologies were AMI (38.3%), ischaemic cardiomyopathy (ICM) (38.0%) and non-ischaemic cardiomyopathy (NICM) (23.7%). Overall, thrombus resolution was significantly higher in DOAC treated patients, but this was driven by the AMI sub-group (P = 0.018). Direct oral anticoagulant use independently predicted thrombus resolution (OR 2.0, 95% Cl 1.29-3.24, P = 0.010). Major bleeding events (BARC ≥3) were more common with VKA use (P = 0.008). Non-ischaemic cardiomyopathy had the highest SSE rate (15.3%, P = 0.002), which were significantly raised in those treated with DOAC (P < 0.001). CONCLUSION:The underlying aetiology of LV dysfunction significantly influences both treatment response and outcomes in patients with LV thrombus. Direct oral anticoagulant were associated with superior efficacy and safety in AMI-related LV thrombus, but were linked to increased rates of SSE in NICM. These findings highlight the importance of aetiology on LV thrombus management and the potential need for tailored approaches.

The management of direct oral anticoagulants (DOAC) during percutaneous coronary interventions is a common challenge in clinical practice. The periprocedural management remains highly variable and insufficiently evidence based. This review summarizes the pharmacokinetic properties of DOACs, evaluates contemporary guideline recommendations, and examines observational and prospective evidence for interruption versus continuation strategies in coronary and structural interventions. For percutaneous coronary interventions, predominantly via radial-access, observational evidence suggests that uninterrupted DOAC therapy is associated with low rates of bleeding and thromboembolism, questioning the routine practice of pre-procedural interruption in low-risk cases. In contrast, patients undergoing transcatheter structural interventions are older, requiring femoral access, and have a higher baseline bleeding risk. In this setting, recent data do not support routine continuation of anticoagulation. We propose a patient- and procedure-specific approach to DOAC management that prioritizes access site, procedural complexity, and renal function over uniform interruption protocols. There is a need for targeted prospective randomized studies on periprocedural and immediate postprocedural management in these populations.

Background Early discharge after primary percutaneous coronary intervention can increase the efficiency of health care, enabling cost savings. Dedicated virtual follow-up pathways can provide remote diagnostic information to aid earlier discharge, optimize care and reduce unplanned readmissions. Objectives The aims of this study were: 1) to review the long-term (1-year) safety of early hospital discharge (<48 hours) after ST-segment elevation myocardial infarction; 2) to assess the effect of virtual follow-up on medication adherence and ability to up-titrate secondary prevention medication; and 3) to determine the cost-effectiveness of a virtual follow-up pathway after early discharge. Methods Between April 2020 and March 2023, 1,500 low-risk patients were discharged at <48 hours and placed on the early hospital discharge follow-up pathway. Patients were reviewed by structured virtual follow-up at 48 hours; 2, 4, and 8 weeks; and 3 and 12 months. Results The median length of hospital stay was 24.9 hours (Q1-Q3: 22.8-36.4 hours), with a minimum of 17 hours and a maximum of 40 hours. Seventy-three percent of patients (1,095 of 1,500) stayed 1 fewer night in the hospital compared with normal pathways. The median length of stay for the control group was 68.1 hours (Q1-Q3: 56-80 hours) (P < 0.0001). During 12-month follow-up, there was a low major adverse cardiac event rate of 3.1% (47 of 1,500) including 0.6% (9 of 1,500) for all-cause mortality and 0.13% (2 of 1,500) for cardiovascular mortality in the early hospital discharge group, which compared favorably with the >48-hour control group (major adverse cardiac event rate 5.5% [77 of 1,400]; P = 0.043). Conclusions Selected low-risk patients can be discharged securely and safely following successful primary percutaneous coronary intervention using a pathway that is reinforced by a formal, multidisciplinary virtual follow-up program, enabling improvements in medication adherence and up-titration.

Public Health England outlines a national ambition of anticoagulating 90% of eligible patients with atrial fibrillation (AF) by 2029. In 2019/2020, two out of three boroughs reviewed in this study were in the bottom 10% of boroughs compared with others within England. Stroke National Audit data for these three boroughs from 2019 to 2020 identified that in patients with known AF admitted to hospital with strokes, 37% were not anticoagulated. Evidence shows that one stroke can be prevented for every 25 patients with AF treated with anticoagulation, reducing the burden of stroke and stroke-related disabilities.In 2020, hospital specialist cardiovascular pharmacists were commissioned to identify patients with AF at high ischaemic risk (CHA2DS2VASc≥2) in three boroughs by working with general practitioners (GPs) and practice-based pharmacists. Using digital ‘proactive care frameworks’ created by UCLPartners and the Clinical Effectiveness Group, Queen Mary University of London, baseline searches of GP records enabled clinical teams to risk stratify and prioritise patients with AF for review. Patients not on anticoagulation were categorised as high risk and were reviewed for initiation of anticoagulation. The second priority was patients on dual antithrombotic therapy to determine if antiplatelet therapy could be stopped to minimise bleeding risk.At baseline (March 2020), nationally available data (extracted from CVDPREVENT) showed that 81% of patients with AF at high ischaemic risk across the three selected boroughs were anticoagulated. Repeated data extraction in March 2023, showed 94% of patients with AF at high ischaemic risk were anticoagulated, an absolute improvement of 13%, with 415 patients initiated on anticoagulant therapy over 3 years, translating to 17 strokes prevented. There was a 52% reduction in dual antithrombotic therapy, preventing an estimated three major bleeds.Improvements were achieved through a combination of specialist pharmacist reviews, GP and practice-based pharmacist training and virtual multidisciplinary reviews supporting the integration of specialists into a primary care setting to enable joined-up pathways for effective stroke prevention.

BACKGROUND AND AIMS:Contrast-induced nephropathy (CIN), also known as contrast-associated acute kidney injury (CA-AKI) underlies a significant proportion of the morbidity and mortality following coronary angiographic procedures in high-risk patients and remains a significant unmet need. In pre-clinical studies inorganic nitrate, which is chemically reduced in vivo to nitric oxide, is renoprotective but this observation is yet to be translated clinically. In this study, the efficacy of inorganic nitrate in the prevention of CIN in high-risk patients presenting with acute coronary syndromes (ACS) is reported.METHODS:NITRATE-CIN is a double-blind, randomized, single-centre, placebo-controlled trial assessing efficacy of inorganic nitrate in CIN prevention in at-risk patients presenting with ACS. Patients were randomized 1:1 to once daily potassium nitrate (12 mmol) or placebo (potassium chloride) capsules for 5 days. The primary endpoint was CIN (KDIGO criteria). Secondary outcomes included kidney function [estimated glomerular filtration rate (eGFR)] at 3 months, rates of procedural myocardial infarction, and major adverse cardiac events (MACE) at 12 months. This study is registered with ClinicalTrials.gov: NCT03627130.RESULTS:Over 3 years, 640 patients were randomized with a median follow-up of 1.0 years, 319 received inorganic nitrate with 321 received placebo. The mean age of trial participants was 71.0 years, with 73.3% male and 75.2% Caucasian; 45.9% had diabetes, 56.0% had chronic kidney disease (eGFR <60 mL/min) and the mean Mehran score of the population was 10. Inorganic nitrate treatment significantly reduced CIN rates (9.1%) vs. placebo (30.5%, P < .001). This difference persisted after adjustment for baseline creatinine and diabetes status (odds ratio 0.21, 95% confidence interval 0.13-0.34). Secondary outcomes were improved with inorganic nitrate, with lower rates of procedural myocardial infarction (2.7% vs. 12.5%, P = .003), improved 3-month renal function (between-group change in eGFR 5.17, 95% CI 2.94-7.39) and reduced 1-year MACE (9.1% vs. 18.1%, P = .001) vs. placebo.CONCLUSIONS:In patients at risk of renal injury undergoing coronary angiography for ACS, a short (5 day) course of once-daily inorganic nitrate reduced CIN, improved kidney outcomes at 3 months, and MACE events at 1 year compared to placebo.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to reduce cardiovascular rehospitalisation in heart failure with reduced ejection fraction (HFrEF) patients. However, it is unknown whether initiating SGLT2i during an inpatient stay for a HFrEF exacerbation results in better outcomes versus initiation post-discharge in a cohort of diabetic and non-diabetic patients. This study compares cardiovascular rehospitalisation, heart failure specific rehospitalisation, cardiovascular death, and all-cause death between patients initiated on SGLT2i as an inpatient versus post-discharge. A retrospective study of four hospitals in England involving 184 patients with HFrEF exacerbations between March 2021 and June 2022 was performed. Cardiovascular rehospitalisation, heart failure specific rehospitalisation, cardiovascular death, and all-cause death were compared between the two groups using Cox regression. A Cox proportionalhazards model was fitted to determine predictors of cardiovascular rehospitalisation. There were 148 (80.4%) individuals who received SGLT2i as an inpatient, while 36 (19.6%) individuals received SGLT2i post-discharge. Median followup was 6.5 months for inpatients and 7.5 months for post-discharge patients (p=0.522). SGLT2i inpatients had significantly reduced cardiovascular rehospitalisations (22.3%) versus post-discharge patients (44.4%) (p=0.005), and significantly reduced heart failure specific rehospitalisations (10.1%) versus post-discharge patients (27.8%) (p=0.018). There was no significant difference in all-cause death (p=0.743) and cardiovascular death (p=0.816) between the two groups. Initiating SGLT2i post-discharge was an independent predictor of cardiovascular rehospitalisation (hazard ratio 2.40, 95% confidence interval 1.31 to 4.41, p=0.005). In conclusion, inpatient SGLT2i initiation for HFrEF exacerbations may reduce cardiovascular and heart failure specific rehospitalisation versus initiation postdischarge. In the absence of contraindications, clinicians should consider initiating SGLT2i once patients are clinically stable during inpatient HFrEF admissions.

Background and Importance Cardiovascular disease (CVD) is a leading cause of mortality worldwide and accounts for approximately 27% of all deaths in United Kingdom. The relationship of hypercholesterolemia to CVD is well established and understood in terms of atherogenesis. Reduction of atherogenic lipoproteins, in particular, low-density lipoprotein with lipid modification treatments has been shown to reduce the risk of CVD events and mortality. Aim and Objectives Design, test and develop an integrated care pathway that utilises specialist cardiovascular pharmacists working with primary care teams. This involves optimising secondary prevention with lipid modification therapy in people with established CVD across 42 General Practitioner practices over one-year pilot programme . Material and Methods Specialist cardiovascular pharmacists were commissioned to work with primary care clinicians to identify, review and optimise secondary prevention in high-risk patients not receiving lipid modification therapy. Eligible patients' clinical notes were reviewed to confirm CVD diagnosis, history of treatment, blood test results and CVD risk factors. Complex cases were reviewed by a virtual lipid specialist multidisciplinary team to agree a treatment plan. Patients were contacted for a virtual consultation to discuss and initiate tailored lipid modification therapy. Results A preliminary review of practices CVD list showed 20% (2200/11233) of patients had a CVD diagnosis and were not receiving lipid modification therapy. A six-month interim analysis of 1100 out of the 2200 clinical reviews conducted by specialist pharmacists, identified that 60% (660/1100) were eligible for statin therapy with only 4% (44/1100) of patients having a true statin intolerance. The remaining 36% (396/1100) were not for lipid modification therapy. Of these patients: 6% (66/1100) declined treatment, 9% (96/1100) were palliative or the risk of treatment outweighed the benefits, 8% (90/1100) had non-atherosclerotic CVD, 9% (100/1100) had incorrect CVD diagnosis and the remaining 4% (44/1100) were no longer part of the practice list. Conclusion and Relevance An integrated care pathway using specialist cardiovascular pharmacists supporting a multidisciplinary workforce within primary care has shown a significant improvement in lipid modification therapy prescribing to reduce the risk of myocardial infarction (MI) and stroke. Extrapolating these results nationally would avert 17,000 MIs and 5,000 strokes over a 5-year period. References and/or Acknowledgements Conflict of Interest No conflict of interest

Background and Importance There are around 100,000 hospital admissions each year in the UK due to acute myocardial infarctions (AMI). Co-morbidities in those with ischaemic heart disease are common and include heart failure, diabetes and chronic kidney disease (CKD), the interplay between these conditions being recently termed cardiometabolic syndrome. Recent updates in UK NICE guidance support the use of SGLT2i for those with type II diabetes (T2DM) and cardiovascular (CV) risk, for treatment in those with heart failure with reduced ejection fraction and most recently for CKD. Aim and Objectives Assess patients at a large London based cardiovascular centre, being previously discharged with a diagnosis of AMI to identify the opportunity to optimise therapy through prescribing SGLT2i. Material and Methods Retrospective analysis of patients admitted with an AMI between January and October 2021 at a large London based cardiovascular centre to compare the optimisation of SGLT2i at discharge (DC) and at 12 months in those with cardiometabolic risk factors (i.e T2DM, HF and CKD). Results 450 patients with AMI were followed during 1 year, average aged of 57.3 years old with 84% male, T2DM (25.7%), HF (23.5%), CKD (10%), 43% smokers and 3% with AF. At discharge, SGLT2i were prescribed in 4.6% of all AMI patients. In patients with T2DM, HF and CKD, the respective rates of SGLT2i at discharge were 18%, 3.7% and 2.2%. At 12 months post-discharge, T2DM increased to 28% (11 newly diagnosed), 23.5% of patients with HF and 16% with CKD (26 patients newly diagnosed). SGLT2i were prescribed in 10.4% of patients with respective rates of 30%, 16% and 11.1%. Conclusion and Relevance This data supports an opportunity to improve SGLT2i prescribing in our post-MI cohort with additional cardiometabolic risk factors. There was a small increase in prescribing noted after 12 months but recent updates in UK policy would support a wider adoption of SGLT2i use, in particular noting the high rates of T2DM and HF seen in the post-AMI group. Strategies to facilitate optimisation include protocolisation of initiation, communication for 1ry care physicians to start shortly after discharge and consideration of earlier initiation prior to discharge in those with cardiometabolic risk factors. References and/or Acknowledgements Conflict of Interest No conflict of interest

For patients with cardiac implantable electronic devices (CIEDs), arrythmias such as atrial fibrillation (AF) can be detected and actions taken to rapidly assess and initiate treatment where appropriate. Actions include timely initiation of anticoagulation, review of blood pressure, and optimization of cholesterol/lipids to prevent unfavorable outcomes, such as stroke and other cardiovascular complications. Delays to initiating anticoagulation can have devastating consequences. We sought to implement a virtual clinic, where a pharmacist reviews patient referrals from a CIED clinic after detecting AF from the CIED. Anticoagulation choice is determined by patient-specific factors, and a shared patient-provider decision to start oral anticoagulation is made. In addition, blood pressure readings and medications are assessed with lipid-lowering therapies for optimization. A total of 315 patients have been admitted through this clinic and anticoagulated over a two-year span; in addition, 322 successful interventions were made for optimization of cardiac therapy. Rapid initiation of anticoagulation within five days of referral was likely to have reduced unfavorable outcomes, such as stroke and other cardiovascular optimizations, leading to improved patient outcomes.

Introduction Cardiovascular Disease (CVD) is the leading cause of morbidity and mortality in England. There are 130,00 people living with CVD across North East London (NEL), claiming 220 deaths each year. The relationship of hypercholesterolaemia to CVD is well established, with every 1 mmol/L reduction in Low Density Lipoprotein (LDL) sustained for 5 years, provides a 22% reduction in CVD events. The national primary care audit has shown only 26% of people with CVD across NEL are on optimal statin with a non-HDL < 2.5mmol/L (LDL <1.8mmol/L) and 16% are not on any lipid modification therapy. NEL integrated care board is focused on working in partnership to streamline services across secondary and primary care to address health inequalities, improve outcome and deliver high-quality service. Through the NEL CVD prevention (ELoPE) programme, a new multidisciplinary Clinical Pathway Initiative (CPI) was developed to test innovative integrated services that utilises specialist hospital teams working with primary care teams to optimise CVD prevention across the local population. Method Redbridge was defined as the first borough to test the CPI. The cohort of people were identified using the UCLPartners Lipid Management Proactive Care Frameworks across 42 practices over a 12-month period, from September 2022. Specialist cardiovascular pharmacists working with primary care clinicians to identify, review and optimise secondary prevention in high-risk people living with CVD and not receiving a lipid modification therapy. Clinical notes were reviewed to confirm CVD diagnosis, history of treatment, bloods results and CVD risk factors. Complex cases were reviewed by a virtual lipid specialist multidisciplinary team to agree a treatment plan. Patients were contacted for a virtual consultation to discuss and initiate tailored lipid modification therapy. Results A review of GP practices list showed that 20% (2,220/11,233) of people living with CVD in Redbridge were not receiving any lipid modification therapy (see figure 1). Of this group, 60% (1,335/2,220) were previously prescribed one or more statins. This cohort was reduced to 13.4% as shown in figure 2. By the end of 12 months, 22% (495/2,220) people were rechallenged and (re)initiated on a statin with 2% (51/2,220) receiving a non-statin lipid lowering therapy. Personalise care adjustments were coded for 10% (220/2,220), 5% (110/2,220) declined treatment and 22% (480/2,220) removed from the CVD registers or practice list. Conclusion A new CPI has established a new service model with a collaborative patient centred approach of secondary care specialist and primary care workforce working together in improving lipid lowering therapy by 24% for people living with CVD and not on a statin. This will prevent 49 CVD events in Redbridge in the next five years. Extrapolating these results for NEL would prevent 458 CVD events over a 5-year period, addressing the NHS long term plan ambition for reducing 150,00 premature CVD deaths by 2029. Conflict of Interest None

Recently, there has been growing interest in the early discharge strategy for low-risk patients who have undergone primary percutaneous coronary intervention (PCI) to treat ST-segment elevation myocardial infarction (STEMI). So far findings have suggested there are multiple advantages of shorter hospital stays, including that it could be a safe way to be more cost-and resource-efficient, reduce cases of hospital-acquired infection and boost patient satisfaction. However, there are remaining concerns surrounding safety, patient education, adequate follow-up and the generalisability of the findings from current studies which are mostly small-scale. By assessing the current research, we describe the advantages, disadvantages and challenges of early hospital discharge for STEMI and discuss the factors that determine if a patient can be considered low risk. If it is feasible to safely employ a strategy like this, the implications for healthcare systems worldwide could be extremely beneficial, particularly in lower-income economies and when we consider the detrimental impacts of the recent COVID-19 pandemic on healthcare systems.

Abstract Introduction Direct oral anticoagulants (DOACs) are favoured over oral vitamin K antagonists (VKA) due to their fixed-dose regimen and reduced thromboembolic and bleeding risk. Despite clear dose adjustments based on patient characteristics, several observational studies have demonstrated 15-20% of patients being overdosed or underdosed when compared to licensing.1,2 Inappropriate dosing can lead to harm e.g., bleeding or thrombosis which would prolong/escalate hospital stay. Aim To assess clinical appropriateness of inpatient DOAC prescriptions across multiple sites of a large London based NHS Trust. Methods This study was conducted retrospectively over a seven month-period across 4 sites from a large London based NHS Trust from November 2021. Electronic prescribing system was used to generate daily reports that enabled a specialist haematology pharmacist to assess all adult inpatient DOAC prescriptions for appropriateness as per product licensing for indication. The report included patient characteristics (age, gender, body weight), prescribed DOAC (agent, dose, indication), serum creatinine, hospital site. Queries were escalated for review by the pharmacy or medical teams. Type of intervention (dose, agent, or no change) was recorded, and allocated a clinical severity rating using IMPACCTS.3 This scale runs from a score of 1 indicating a good practice intervention to a score of 5 that prevents serious or major harm including death. This study was approved by the University College London (UCL) School of Pharmacy research ethics committee. Results A total of 1,761 inpatient DOAC prescriptions were reviewed, of which 10.1% had a clinical query requiring escalation. Results demonstrate that 77.0% (n=137) of all queries were dose-related, 33.2% overdosed and 43.8% underdosed compared to licensing, the most common agent requiring adjustment being apixaban. Renal-related queries were most frequently observed (50.6%), with 12.8% of patients on edoxaban having CrCl >110ml/min. We found that 2.3% of prescription queries raised required review and stopping antiplatelet agents co prescribed with anticoagulation. Most interventions made had a severity rating of 4 (74.2%), followed by 15.2%, and 10.7% had a score of 1 and 3, respectively. Following pharmacist recommendations, changes made were either dose (38.7 %) or agent (14.6%). Alternatively, it was not applicable due to a change in clinical status, i.e., renal function improved (1.1%) or patient re-weighed (6.2%). Changes to prescriptions did not apply to some patients as documentation of clinical reasoning were recorded (19.7%), or due to patients being discharged (13.5%). Discussion/Conclusion This study has demonstrated a significant number of DOAC prescriptions are inappropriate at the point of prescribing when compared to product summary of characteristics for the indications listed. The use of a centralised report to assess appropriateness of DOAC prescribing across several sites has facilitated a centralised mechanism led by a haematolgy specialist to improve safer DOAC prescribing. The most frequent interventions being made included dose amendments based on calculated creatinine clearance and amending (or adding) indications entered on the system. Further work is required to demonstrate effective change management strategies that have been implemented to further improve the safety of DOAC prescribing within the Trust. References 1. Yao X and Noseworthy P. NOAC dosing and monitoring: really as simple as it seems?: BMJ Publishing Group Ltd and British Cardiovascular Society; 2020;321-2. 2. Garcia Rodriguez L.A., Martin-Perez, et al. 2019. Appropriateness of initial dose of non-vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation in the UK. BMJ open, 9, e031341-e031341. 3. Ali F et al. Content validity IMPACCTS – instrument for rating clinical pharmacy care contributions. United Kingdom Clinical Pharmacy Association Symposium Proceedings; 2021.

Aim Current guidelines recommend the use of vitamin K antagonist (VKA) for up to 3-6 months for treatment of left ventricular (LV) thrombus post-acute myocardial infarction (AMI). However, based on evidence supporting non-inferiority of novel oral anticoagulants (NOAC) compared to VKA for other indications such as deep vein thrombosis, pulmonary embolism (PE), and thromboembolic prevention in atrial fibrillation, NOACs are being increasingly used off licence for the treatment of LV thrombus post-AMI. In this study, we investigated the safety and effect of NOACs compared to VKA on LV thrombus resolution in patients presenting with AMI. Methods and results This was an observational study of 2328 consecutive patients undergoing coronary angiography percutaneous coronary intervention (PCI) for AMI between May 2015 and December 2018, at a UK cardiac centre. Patients' details were collected from the hospital electronic database. The primary endpoint was rate of LV thrombus resolution with bleeding rates a secondary outcome. Left ventricular thrombus was diagnosed in 101 (4.3%) patients. Sixty patients (59.4%) were started on VKA and 41 patients (40.6%) on NOAC therapy (rivaroxaban: 58.5%, apixaban: 36.5%, and edoxaban: 5.0%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous myocardial infarction, PCI, coronary artery bypass grafting), and cardiovascular risk factors (hypertension, diabetes, hypercholesterolaemia). Over the follow-up period (median 2.2 years), overall rates of LV thrombus resolution were 86.1%. There was greater and earlier LV thrombus resolution in the NOAC group compared to patients treated with warfarin (82% vs. 64.4%, P=0.0018, at 1 year), which persisted after adjusting for baseline variables (odds ratio 1.8, 95% confidence interval 1.2-2.9). Major bleeding events during the follow-up period were lower in the NOAC group, compared with VKA group (0% vs. 6.7%, P=0.030) with no difference in rates of systemic thromboembolism (5% vs. 2.4%, P=0.388). Conclusion These data suggest improved thrombus resolution in post-acute coronary syndrome (ACS) LV thrombosis in patients treated with NOACs compared to VKAs. This improvement in thrombus resolution was accompanied with a better safety profile for NOAC patients vs. VKA-treated patients. Thus, provides data to support a randomized trial to answer this question.

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction: Cardiac implantable electronic devices (CIED) enhance detection of atrial fibrillation (AF), providing a comprehensive measure of AF burden. Patients with device-detected AF are usually referred for anticoagulation to their local anticoagulation clinic or General Practitioner (GP), which often delays time to initiation, potentially increasing the risk of stroke. In addition, AF is associated with increased risk of cardiovascular disease and mortality. Optimising blood pressure, cholesterol and lifestyle choices can significantly reduce the risk of cardiovascular disease and associated mortality in these patients. Purpose To develop and evaluate an innovative pathway to allow Specialist Cardiac Pharmacists to promptly assess and initiate anticoagulation in patients with device-detected AF, and additionally address risk factors for prevention of cardiovascular disease. Methods As part of a quality improvement initiative, a pathway was developed where patients with AF identified on CIED who require anticoagulation are referred for assessment and management to a pharmacist-led optimisation clinic. Specialist Cardiac Pharmacists contact patients within 5 days of referral to discuss and initiate or optimise treatment for AF, blood pressure, cholesterol and lifestyle choices. Patients deemed inappropriate for anticoagulation were referred back to the medical team for further assessment. All patients received a follow-up telephone consultation at 4-6 weeks to assess tolerability, adherence and response to treatment. Results Between September 2020 and February 2021, 22 patients were referred to the optimisation clinic. Mean age was 74.32 +/- 12.34 years and 77% were men. Mean CHA2DS2VASc was 3.4 +/- 0.8 and mean HASBLED was 1.2 +/- 0.6. The average time from referral to anticoagulation was 3 days compared to 4 weeks prior to implementation of the pathway. All patients were assessed and appropriately anticoagulated, whereas approximately 15% of patients were still not anticoagulated at 3 months prior to implementation of the pathway despite referral to their local clinic. All patients had their blood pressure and cholesterol reviewed, which were optimised in 23% and 41% of patients respectively. All patients confirmed adherence and suffered no adverse effects on follow-up. Conclusion(s): We report the safe and successful implementation of a pharmacist-led medicines optimisation clinic. This has significantly reduced time to anticoagulation without compromising safety, as well as assuring all patients are appropriately anticoagulated. In addition, over half of patients required blood pressure and/or cholesterol optimisation to reduce the risk of cardiovascular disease, a service not previously provided for this cohort of patients.

BACKGROUND Regional heart attack services have improved clinical outcomes following ST-segment elevation myocardial infarction (STEMI) by facilitating early reperfusion by primary percutaneous coronary intervention (PCI). Early discharge after primary PCI is welcomed by patients and increases efficiency of health care. OBJECTIVES This study aimed to assess the safety and feasibility of a novel early hospital discharge pathway for lowrisk STEMI patients. METHODS Between March 2020 and June 2021, 600 patients who were deemed at low risk for early major adverse cardiovascular events (MACE) were selected for inclusion in the pathway and were successfully discharged in <48 hours. Patients were reviewed by a structured telephone follow-up at 48 hours after discharge by a cardiac rehabilitation nurse and underwent a virtual follow-up at 2, 6, and 8 weeks and at 3 months. RESULTS The median length of hospital stay was 24.6 hours (interquartile range [IQR]: 22.7-30.0 hours) (prepathway median: 65.9 hours [IQR: 48.1-120.2 hours]). After discharge, all patients were contacted, with none lost to follow-up. During median follow-up of 271 days (IQR: 88-318 days), there were 2 deaths (0.33%), both caused by coronavirus disease 2019 (>30 days after discharge), with 0% cardiovascular mortality and MACE rates of 1.2%. This finding compared favorably with a historical group of 700 patients meeting pathway criteria who remained in the hospital for >48 hours (>48-hour control group) (mortality, 0.7%; MACE, 1.9%) both in unadjusted and propensity-matched analyses. CONCLUSIONS Selected low-risk patients can be discharged safely following successful primary PCI by using a pathway that is supported by a structured, multidisciplinary virtual follow-up schedule. (C) 2021 by the American College of Cardiology Foundation.

Background: Contrast-induced nephropathy (CIN), an acute kidney injury resulting from the administration of intravascular iodinated contrast media, is a significant cause of morbidity/mortality following coronary angiographic procedures in high-risk patients. Despite preventative measures intended to mitigate the risk of CIN, there remains a need for novel effective treatments. Evidence suggests that delivery of nitric oxide (NO) through chemical reduction of inorganic nitrate to NO may offer a novel therapeutic strategy to reduce CIN and thus preserve long term renal function. Design: The NITRATE-CIN trial is a single-center, randomized, double-blind placebo-controlled trial, which plans to recruit 640 patients presenting with acute coronary syndromes (ACS) who are at risk of CIN. Patients will be randomized to either inorganic nitrate therapy (capsules containing 12 mmol KNO3) or placebo capsules containing potassium chloride (KCl) daily for 5 days. The primary endpoint is development of CIN using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. A key secondary endpoint is renal function over a 3-month follow-up period. Additional secondary endpoints include serum renal biomarkers (e.g. neutrophil gelatinase-associated lipocalin) at 6 h, 48 h and 3 months following administration of contrast. Cost-effectiveness of inorganic nitrate therapy will also be evaluated. Summary: This study is designed to investigate the hypothesis that inorganic nitrate treatment decreases the rate of CIN as part of semi-emergent coronary angiography for ACS. Inorganic nitrate is a simple and easy to administer intervention that may prove useful in prevention of CIN in at-risk patients undergoing coronary angiographic procedures.

IntroductionApproximately 20% of patients suffer from major adverse cardiovascular events (MACE), within 5 years of stopping dual antiplatelet therapy (DAPT), following an acute coronary syndrome (ACS) event. As such, prolonged DAPT, with aspirin and ticagrelor, has shown significant reductions in MACE, offset by an increased risk of major bleeding. The DAPT score offers a means to predict those who would derive benefit from prolonged therapy. We sought to evaluate applicability of the DAPT score to our population in a tertiary heart attack unit. Method Anonymised data was reviewed as part of a larger quality improvement initiative associated with management of ACS. ACS was defined according to standard international criteria. DAPT scores were calculated and compared against our cohort of patients who would have met criteria for prolonged DAPT as per PEGASUS. Patients were excluded if they were at high risk of bleeding, as assessed using CRUSADE scores ≥ 41, or required anticoagulation.ResultsBetween September to December 2019, 304 patients presented with ACS, of which 89 patients were excluded due to high bleeding risk (56) and concomitant anticoagulation (33). 38 patients were excluded as there was insufficient data to calculate DAPT scores. Of the remaining 177 patients, 55% met PEGASUS criteria for prolonged DAPT, largely driven by multivessel disease (66%). When undertaking the DAPT score, this suggested benefit from prolonged DAPT in 53% of patients meeting PEGASUS criteria.ConclusionApplying the DAPT score identified just upward of 50% of patients that may benefit from prolonged DAPT. Patients over the age of 65 is a key inclusion criterion in PEGASUS that derived benefit from prolonged therapy; however, is also a risk factor for major bleeding and as such, a negative predictor factor in the DAPT score. This may contribute to the 50% of patients who met criteria for prolonged DAPT as per PEGASUS but would not warrant prolonged DAPT when applying the DAPT score. This review suggests that risk stratification through use of a suitable risk tool (DAPT score) may help to widen the risk benefit of prolonged DAPT by excluding those likely to bleed while ensuring patients at highest ischemic risk are appropriately targeted.Conflict of InterestNone

Background Cardiovascular disease (CVD) is the leading cause of mortality worldwide, totalling almost one-third of all deaths. Lipid optimisation is a key public health priority to decrease CVD morbidity, mortality and consequential economic burden on healthcare systems. A reduction in cholesterol by 1 mmol with statin therapy reduces the risk of CVD events by 20%–24%, in people with an estimated 10 year CVD risk greater than 10%. In the UK, the National Institute of Clinical Excellence (NICE) recommends atorvastatin 20 mg for primary prevention of CVD in these people, using QRISK2 to estimate their level of risk. Purpose To assess adherence to NICE lipid modification guidance in patients presenting with acute coronary syndrome (ACS). Material and methods Data on lipid-lowering therapy was collected prospectively, over an 8 week period in August 2018, for all patients presenting with ACS. QRISK2 scores were calculated for patients admitted with ACS naïve to statin therapy. Ethics approval was not required. Results Two-hundred and fifty-two patients presented with ACS: mean total cholesterol and low-density lipoprotein (LDL) levels on admission were 4.7 and 2.8 mmol/L respectively. One-hundred and thirty-six (54%) patients were naïve to statin therapy prior to admission, of these 91 (67%) had a QRISK2 score greater than 10% (mean 18.45%). All patients were subsequently discharged on high-intensity statins, 124 (91%) on atorvastatin 80 mg. Conclusion Two-thirds of patients naïve to statin therapy prior to admission had a 10 year CVD risk of 10% or greater, as estimated using QRISK2, and would have been eligible for atorvastatin 20 mg for primary prevention of CVD as per NICE guidance. Identifying patients in primary care at risk of CVD events is key to ensuring appropriate lifestyle modifications are undertaken and statin therapy initiated, both of which have been shown to reduce CVD event rates. Community services, such as NHS health checks at community pharmacies, and development of GP practice-based pharmacists should be targeted and supported by secondary care to ensure high-risk patients are prescribed optimum lipid modification therapy for primary prevention of CVD, thereby reducing the risk of CVD morbidity, mortality and associated financial implications to the health system. References and/or acknowledgements https://www.nice.org.uk/guidance/cg181/chapter/1-Recommendations#lipid-modification-therapy-for-the-primary-and-secondary-prevention-of-cvd-2 No conflict of interest.