Weight Loss and Atrial Fibrillation; DAPT After Bypass Surgery

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of Texas Tech Health El Paso, look at the top medical stories of the week.

This week’s topics include duration of dual antiplatelet therapy (DAPT) following bypass grafting or stents, changes in management of miscarriage, at-home rehab after an intensive care unit (ICU) stay, and weight loss for atrial fibrillation.

Program notes:

0:48 Management of spontaneous abortion after Dobbs v. Jackson

1:48 States with trigger bans versus those without

2:49 Changes in medical management in trigger ban states

3:49 Negative impact on women’s health

4:49 Rural residents more often

5:20 Does weight loss prevent atrial fibrillation?

6:20 Older age and longer duration predict negative results

7:00 Rehab after an ICU stay

8:00 Individualized and delivered at home

9:00 429 randomized participants

10:01 Maybe requires longer time

10:31 Dual antiplatelet after stents or bypass

11:32 Three months and 12 months had 11% occlusion

12:43 End

Transcript:

Elizabeth: How has management of spontaneous abortion, otherwise known as miscarriage, changed since the Dobbs v. Jackson Supreme Court decision?

Rick: How long should you take two antiplatelet agents after you’ve had a bypass surgery?

Elizabeth: Can we create an at-home rehabilitation program for people who have survived an ICU stay?

Rick: And does reducing body weight in obese patients reduce their symptoms of atrial fibrillation?

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, president of Texas Tech Health El Paso.

Elizabeth: So Rick, let’s turn to JAMA. And I’d like to take a look at this one that you commented, “Ooh, that was a long intro, Elizabeth.” And that’s the management of spontaneous abortion among commercially insured individuals in the United States after the Supreme Court’s decision Dobbs v. Jackson.

The study reminds us that spontaneous abortion, or what’s commonly called miscarriage, is the most common complication of early pregnancy and requires the same treatment options as induced abortion. These investigators identified 124,000 approximately people aged 15 to 45 years with spontaneous abortion at fewer than 77 days of gestation from Jan. 1, 2018, through Sept. 30, 2024. A difference-in-differences framework compared the management changes from that pre-policy decision of the Supreme Court to the post-policy decision. They were looking at 14 states that had trigger bans versus 17 comparison states that did not have those.

In those states that had a trigger ban, there was a 2.8-percentage point increase in expected management — and expected management, of course, that’s waiting to see how the person does after this initiation of spontaneous abortion versus doing anything — and a 2.2-percentage point decrease in medication management in those states. There was no significant change in surgical management. They point out that among individuals receiving medication, trigger bans were associated with a relative almost 14-percentage point increase in misoprostol-only regimens.

I’ll remind you that it’s the mifepristone that is the medication that has been back in the news recently with another Supreme Court decision right now allowing it to still be mailed.

So, it looks like there’s a changing dynamic among women whose spontaneous abortions are being managed in states that have trigger bans secondary to the Supreme Court’s decision versus those that do not.

Rick: And Elizabeth, for our listeners that may not be familiar, when we talk about a trigger ban, that means abortion is restricted [to] before 6 weeks. Most of these spontaneous abortions occur between 8 and 9 weeks.

Elizabeth: I think it’s concerning because it suggests that both hospitals and policymakers and states that have trigger bans are bowing to what they perceive as political pressure to not use what is the recommended strategy for women who require medication management with both agents versus just one alone, which is less effective. That is what the evidence has shown and people are stepping away from that.

The authors point out also that there’s been a migration away from states with trigger bans by obstetrician-gynecologists because of this perception that their practice is being scrutinized really closely. And I think that all of this has a very negative impact on women and on women’s health.

Rick: Yep. Again, in perspective, there are 400,000 miscarriages annually in the United States, particularly in states with abortion bans. If you’re not using the proper treatment as medications, mifepristone pretreatment, it actually means that the mother is more likely to need some intervention afterwards, some procedure, and that’s what we’re trying to avoid.

It’s disconcerting, again, that these are the recommendations for the safety of the mother and guideline-based, and individuals aren’t following it just because they’re concerned about the potential fallout. But it’s clear they’re not being used for abortion. The baby is already spontaneously aborted. At this particular point, all we’re trying to do is we’re trying to make it safe for the mother. So we have a lot of education to do.

Elizabeth: I would note that they also say that trigger-ban states, those women who were in those states and captured in this data were slightly younger than those in the comparison states, more likely to reside in rural areas where they’re already not getting the best care and to receive their diagnosis in the ED [emergency department], a constellation of things that already are associated with poor outcomes that are being exacerbated by this particular situation.

Rick: Yeah. What are your thoughts regarding moving forward?

Elizabeth: What you said about education and about basically encouraging clinicians to practice according to the evidence.

Rick: Yeah. We need to get rid of the legal ambiguity, the fear of criminal liability, and just the confusion.

Let’s stay in JAMA and let’s talk about does weight loss prevent atrial fibrillation. This is the most common sustained arrhythmia that’s encountered in clinical practice. Now we realize it’s actually a preventable disorder.

One of the risk factors for it happens to be obesity. Well, these investigators decided to do a randomized trial where they took individuals ages 60 to 85 that had persistent atrial fibrillation and randomized them to either an 8-month low-calorie diet with behavioral support or another 60 patients to just usual care.

What they discovered is the individuals that were put on the low-calorie diet lost less than 10% of their body weight. Those that were in the usual care lost about 3%. Then when they looked at the atrial fibrillation symptom severity score, there was no difference between the two. In fact, there was no significant difference observed on physical performance, some cardiac imaging parameters, or even blood pressure, lipid profile, or the incidence of repeat cardioversion or atrial fibrillation ablation during follow-up. This was a little discouraging. Older age and longer duration of atrial fibrillation makes it less likely to be successful to treatment, like ablation, so it may not be terribly surprising that those individuals are also not receiving any benefit from weight reduction.

Elizabeth: One place where weight reduction does not seem to improve a chronic condition.

Rick: I don’t want to say that weight reduction shouldn’t be encouraged. We’ve talked about the other reasons why it could be beneficial. We may need to apply it earlier once someone has developed atrial fibrillation and extend it to younger patients as well.

Elizabeth: Remaining in JAMA then, our ability to create a successful rehabilitation program for those who have survived an intensive care unit stay. That’s a lot of folks. And there’s a syndrome that’s actually called post-intensive care syndrome, or PICS, that has become quite an area of emphasis for many people I know. We know that when somebody’s been in the ICU, they have a lot of deconditioning. Many people have PTSD [post-traumatic stress disorder]. Other things like depression.

These investigators were looking at whether a remote, multicomponent, rehabilitation program could help to get people back to their previous level of functioning or at least an acceptable level of functioning faster. This was done in the U.K. Participants were adults who had been discharged from the hospital within the last 12 weeks with an ICU admission and they required mechanical ventilation. They were randomized to a 6-week, remote, multicomponent, individualized, rehabilitation intervention that used weekly symptom management, targeted exercise, psychological support, peer support during that time period. And it began within those 12 weeks of hospital discharge. They had 231 people who did that and standard care in 198.

They employed a measure that’s called the EuroQoL 5-dimension 5-level questionnaire utility score, which measured their quality of life at 8 weeks. And this is what I love. This score actually ranges from -0.285, which is worst possible functioning, worse than dead, to a score of 1, which is the best health. They also looked at secondary outcomes, including leg strength, exercise capacity, self-reported perception of fatigue, anxiety, or depression, their illness perception, and acceptability of the intervention and adverse events.

Tellingly, they screened 3,700+ patients. They got 429 randomized and this was because these patients declined to participate for the most part. They really did not show any improved health-related quality of life at 8 weeks after discharge. When they divided the mechanical ventilation group into those who required it for less than 2 weeks versus those who were on it for a more prolonged period of time, they were able to show that there was a slight benefit. So rather disappointing.

Rick: Here’s the thing I found fascinating about this study is they did this multicomponent intervention over 6 weeks. And as you said, it was pretty intensive. When they came back 6 months [later], those that participated in the exercise program actually improved at 6 months. Leg strength, exercise capacity, fatigue, anxiety, and those were all improved as well. If you just restrict it to 8 weeks, you may not see much of a benefit. But if you extend the observation out for a longer period of time, it did appear to me beneficial. What are your thoughts?

Elizabeth: Well, it was a little bit beneficial, but not overwhelmingly beneficial. Maybe it does require a lot longer time for people to participate. They also note 88% of their participants were fully adherent to the program, which is pretty good.

Rick: It is. I’m not willing to give up on this. I do think it needs additional studies.

Elizabeth: The authors speculate that maybe we should have such an animal as what they call an aftercare facility for those people who have survived an ICU stay to help them with this rehabilitation effort.

Let’s turn to your last one, and that’s in The BMJ.

Rick: How long should you take dual antiplatelet therapy after one has had bypass surgery?

Dual antiplatelet therapy with aspirin plus another antiplatelet agent is routine therapy for people that have had a stent and also for people that have had bypass surgery. Current recommendations are to continue it for at least a year because at that point, the graft will have been fully healed and it’s less likely to have a clot form in it. But the longer you continue these dual antiplatelet therapy, the more common it is to have bleeding risk. So we’re trying to balance efficacy versus bleeding. Maybe it doesn’t take 12 months, maybe 3 months would be sufficient.

Thirteen different cardiac surgery centers in China between February of 2023 and July of 2024. They enrolled 2,300 participants that had one or more vein grafts placed. And these were put on dual antiplatelet therapy with ticagrelor and aspirin. Both agents were continued for 12 months in one group or only 3 months. Those who received both platelet agents for 3 months, at the end of 3 months, they just continued aspirin.

In both groups, about 11% of the grafts had occluded by 12 months, regardless of whether they received 3 months of dual antiplatelet or 12 months. When they looked at the bleeding incidents, though, those that received 3 months of dual antiplatelet therapy had bleeding in about 8% of patients and those who received 12 months had it about 13%. We should probably be stopping dual antiplatelet therapy at 3 months to decrease the bleeding risk.

Elizabeth: Well, that’s good news, of course, because most people would rather take fewer medicines than taking more medicines. I guess this also suggests to me that if one in nine of them are occluding over this time period, we probably need something else that’s going to be helpful with that.

Rick: And I wish there was. This has been studied for years. The fact that we have about 90% open at the end of the year is still pretty good, all things considered.

Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.

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