Jessie J diagnosed with early breast cancer
Singer Jessie J has been diagnosed with "early breast cancer".
The Price Tag singer, whose real name is , said in a video posted to Instagram that she has recently spent a lot of time "in and out of tests".
She said she will "disappear for a bit" after performing at Capital Radio's Summertime Ball later this month to have surgery.
"I was diagnosed with early breast cancer," the 37-year-old said during the video.
"Cancer sucks in any form, but I'm holding on to the word 'early'.
"It's a very dramatic way to get a boob job. I am going to disappear for a bit after Summertime Ball to have my surgery, and I will come back with massive tits and more music."
'I need a hug'
Breast cancer is the most common type of cancer in women in the UK.
The singer said sharing her diagnosis publicly has helped her process the news and show solidarity with others going through a similar experience.
"I just wanted to be open and share it," she said.
"One, because, selfishly, I do not talk about it enough. I'm not processing it because I'm working so hard.
"I also know how much sharing in the past has helped me with other people giving me their love and support and also their own stories. I'm an open book.
"It breaks my heart that so many people are going through so much similar and worse - that's the bit that kills me."
She continued: "The timing of it has been mad but also beautiful and given me this incredible perspective in this time.
"But honestly I need to process it and talk about it and, I need a hug. You have loved me through all my good and hard times. And I don't want this to be any different."
'I'm here for you'
Messages of support from celebrities flooded the comments section under the singer's post.
Former Little Mix singer Leigh-Anne Pinnock wrote: "Sending you so much love."
Fellow singer Rita Ora said: "You're literally my favourite person and I'm praying for you, you've got this. My mother had it and I know the surgery and any treatment on this matter is mentally tough, so I'm here for you."
Read more from Sky News:
London-born singer Jessie J welcomed her son, Sky Safir Cornish Colman, in 2023, having .
She has battled with ill health throughout her life, having been diagnosed with a heart condition aged eight, suffering a minor stroke aged 18 and having briefly gone deaf in 2020.
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San Francisco Chronicle
37 minutes ago
- San Francisco Chronicle
New S.F. Pride festival loses headliner weeks before event
Oakland R&B singer Kehlani has pulled out of the lineup for San Francisco's new Pride celebration, SoSF, leaving the event without a main headliner three weeks before it's scheduled to take place. The festival, a new one-day block party, announced that the 'After Hours' singer has decided to no longer be a part of the line-up' in an Instagram post shared on Thursday, June 5. Organizers also announced that the event, set for June 28, will no longer be held at Pier 80's warehouse. Instead, it will take place outdoors at 900 Marin Street, just across the street from the original location. The Chronicle has reached out to SoSF for more information. 'Nasty' singer Tinashe and Grammy-winning pop artist Kim Petras remain on the updated bill as headliners, and German DJ and Portola Festival alum Horsegirl has been added as a special guest. Still others on the festival's roster appear to be in flux. San Francisco DJ Adam Kraft, the 'Reparations' drag show and event company Fake and Gay have also dropped out of the lineup according to an Instagram story post from Kraft, which Fake and Gay then reposted. Kraft teased that a statement on the artists' decision to drop out would be 'prepared soon.' None of these acts are listed on the SoSF website anymore. Kehlani has been under fire recently for her stance on the war in Gaza. Her performance at Cornell University's end-of-school-year Slope Day was nixed by the school's president in April due to what he deemed 'antisemitic, anti-Israel sentiments." The artist has frequently used her platform to speak out in opposition against Israel and Zionism. She included keffiyehs, traditional Arabic scarves often associated with Palestinian identity, in the music video for her 2024 song 'Next 2 U,' which also uses the phrase 'long live the intifada,' which translates to 'uprising' or 'resistance' in Arabic. The term is also considered, by some, as a call for violence against Jews. Though the Oakland School for the Arts alum quickly responded via an Instagram video, refuting accusations of antisemitism by clarifying that she is 'anti-genocide' and 'anti the actions of the Israeli government,' more concert cancellations followed.
Business Insider
38 minutes ago
- Business Insider
The stars of 'Stranger Things,' ranked by success
14. Priah Ferguson Ferguson, who plays Lucas' sassy (and almost always correct) little sister Erica Sinclair, is the youngest member of the main cast at 18. She was 11 when she joined "Stranger Things" in season two. Impressively, while she was shooting the show, she was also balancing her studies — she graduated from high school this year. She wrote to her 3.6 million Instagram followers that "balancing an adult career — on and off screen" while maintaining an above-average GPA at her public high school was a "unique journey." Besides playing Erica, Ferguson had roles in the films "The Oath" and "The Curse of Bridge Hollow" (another Netflix joint). She's also had voice roles in animated series "Hamster & Gretel" and "My Dad the Bounty Hunter." Now she's done with school and has more time to focus on her career, we expect Ferguson will appear in more scene-stealing roles. 13. Charlie Heaton Heaton, 31, plays Jonathan Byers, Will's devoted older brother who will do anything to help Will and his mom. He was 22 when the show began, playing a high school sophomore. The British actor hasn't done much outside the show. He was in the calamitous final 20th Century Fox "X-Men" movie, " The New Mutants," in 2020, which essentially doesn't exist. He also stared in the indie movie "No Future," which never had a wide release, and "The Souvenir Part II," which was critically beloved but not a big box-office hit. On the TV front, he only appeared in an episode of the 2020 anthology series "Soulmate." And while he has 5.3 million followers on Instagram, that number doesn't compare to some of the follower counts of his fellow cast members. We'd argue that Heaton's biggest claim to fame is his real-life relationship with Natalia Dyer, his on-screen love interest. 12. Natalia Dyer Speaking of Dyer, 30, she's next up on the list. She plays Nancy Wheeler, Mike's older sister with an investigative streak. Nancy was also involved in a love triangle with her first love, Steve, and Jonathan. She eventually picked Jonathan, but some moments in season four made it seem like a possible "Stancy" reunion is in the cards. Dyer, who was 21 when the show began, has the edge on her boyfriend, Heaton. She's appeared in multiple short films during her "Stranger Things" tenure, and had supporting roles in films like "Velvet Buzzsaw" and "Things Heard & Seen" (both Netflix films). She also had a lead role in the coming-of-age indie "Yes, God, Yes," released in 2020. But it's been five years, and she hasn't been able to parlay that into more leading roles. In 2023, she starred in the first season of the Peacock series "Based on a True Story" alongside Chris Messina and Kaley Cuoco. 11. Eduardo Franco Franco joined the cast in the fourth season of "Stranger Things" as Argyle, Jonathan's stoner best friend in California. Before even joining the show, 30-year-old Franco was well on his way to becoming a zillennial "that guy" — he's had recognizable roles in projects like " Booksmart," "Superintelligence," "Self Reliance," "American Vandal," and "Y2K" just last year. Franco also has had successful voice roles. He starred in "Ruby Gillman, Teenage Kraken," and has been playing DJ Catnip on the hit children's show "Gabby's Dollhouse" since 2021. A feature-length "Gabby's Dollhouse" film is set to premiere this year, with Franco reprising his role. His social media is what takes him down a bit, with 533,000 followers on Instagram. 10. Dacre Montgomery Montgomery was 23 years old when he joined "Stranger Things" in season two as Max's older stepbrother, Billy Hargrove, who made it his personal mission to bully Max, her friends, and even Steve. Now 30, Montgomery has been steadily working, but hasn't gotten his true big break. The same year he joined "Stranger Things," he starred in the ill-conceived "Power Rangers" movie as the Red Ranger. Since then, he had a small role in "Elvis" and starred in the underrated 2020 rom-com "The Broken Hearts Gallery." However, Montgomery has big things coming soon. He has three movies on the docket: "Faces of Death," which costars Barbie Ferreira, Josie Totah, Charli XCX, and Jermaine Fowler; "Dead Man's Wire," which will be directed by Gus Van Sant and costars Bill Skarsgård, Colman Domingo, Myha'la, and Cary Elwes; and "The Engagement Party" which will also be Montgomery's directorial debut. But since those projects haven't come out yet, he can't be too high on this list. 9. Noah Schnapp Schnapp, 20, has played Will Byers, who was originally taken to the Upside Down (a dark parallel universe) in the show's first episode, since he was 12. Pre-"Stranger Things," Schnapp had a small role in "Bridge of Spies" and played Charlie Brown in "The Peanuts Movie." Since playing Will, Schnapp had a small role in "Hubie Halloween" (a Netflix movie) and starred in the indie film "Waiting for Anya," both in 2020. In the five years since, he's had just one other role, appearing in the 2023 thriller "The Tutor," which was a flop critically and financially. There's a reason for his slowdown in work, though — since 2022, he's attended the University of Pennsylvania. He's also leveraged his fame to become a business owner (he started the company TBH, which is a healthier alternative to spreads like Nutella) and YouTuber. He has 4.56 million subscribers on the site, even though he hasn't posted in years. He also has a huge Instagram presence, with 21.4 million followers. Schnapp has mainly been in headlines for his views on the Israel-Hamas conflict. Per Entertainment Weekly, after he made posts supporting Zionism in 2023, some fans called for a boycott of season five (which was then in production) or for Schnapp to be fired. In a January 2024 TikTok post, he said, "I feel like my thoughts and beliefs have been so far misconstrued from anything even close to what I believe." He continued, "I think anyone with any ounce of humanity would hope for an end to the hostility on both sides." 8. Caleb McLaughlin McLaughlin has played Lucas Sinclair, the more levelheaded and skeptical member of the core group, since season one, when he was 15. Now 23, McLaughlin has arguably undergone the biggest transformation — he even has a beard! Like many of his costars, McLaughlin has continued to work with Netflix. He appeared in "High Flying Bird" (directed by Steven Soderbergh), "Concrete Cowboy," and "The Deliverance," all Netflix originals. He had a role in the 2023 biblical comedy "The Book of Clarence," which was a box-office flop but critically well-liked. He also played former NBA player and current college coach Dru Joyce III in "Shooting Stars," a Peacock film about a young LeBron James. "Stranger Things" isn't the only TV show he's done, either. He played Ricky Bell in the BET miniseries "The New Edition Story," and has had voice roles in "Summer Camp Island," "Ultra City Smiths," and "The Boys Presents: Diabolical." 7. Gaten Matarazzo Matarazzo, 22, plays the lovably geeky Dustin Henderson, who formed a bond with older kids Steve and Eddie. He was 14 when the show began airing. Matarazzo has since built himself a very well-rounded career. In addition to his movie roles ("Honor Society," "My Father's Dragon," "Please Don't Destroy: The Treasure of Foggy Mountain" and the upcoming "Animal Farm" remake) and theater roles ("Into the Woods," "Parade," and the original cast of the "Sweeney Todd" revival), Matarazzo has also made himself a TV personality; he executive-produced and hosted the Netflix hidden-camera series "Prank Encounters." 6. Maya Hawke Hawke, 26, joined the show in season three in 2019, when she was 21. She plays Robin Buckley, originally Steve's coworker at Scoops Ahoy, but soon she becomes his best friend. She's also one of the show's two canonically queer characters, alongside Will. Technically, Hawke has been famous since birth, as her parents are Ethan Hawke and Uma Thurman. But 2019 was her breakout year, as she joined "Stranger Things" and appeared in "Once Upon a Time in Hollywood." Like the rest of her costars, Hawke has a good relationship with Netflix. She starred in "Fear Street Part One: 1994," "Do Revenge," and "Maestro," all on the streamer. Besides that, Hawke appeared in the Wes Anderson film "Asteroid City" and the highest-grossing film of 2024, " Inside Out 2." She voiced a new emotion, Anxiety. Next year will be a big one, though. Hawke was announced to be joining the cast of " The Hunger Games: Sunrise on the Reaping" as Wiress, originally played by Amanda Plummer in "Catching Fire." Hawke has a music career, as well. She's released three albums: "Blush" (2020), "Moss" (2022), and "Chaos Angel" (2024). She's set to resume her world tour for "Chaos Angel" this summer. 5. Finn Wolfhard Wolfhard, 22, is the show's lead character, Mike Wheeler. He's the one who decides to go looking for Will after he goes missing and forms a special bond with the mysterious girl they meet in the woods. We know the most about his home life, as his sister Nancy is a main character, and we've met his parents and younger sister, as well. He began playing Mike when he was 13 years old. Wolfhard has two successful franchises to his name. He played young Richie in 2017's " It" (which made $704 million) and 2019's " It Chapter Two" (which made $473 million). He also appeared in " Ghostbusters: Afterlife" and "Ghostbusters: Frozen Empire," which each made around $200 million worldwide. In 2024, he had a small role in "Saturday Night," and this year, he appeared in the A24 film "The Legend of Ochi." His directorial debut, "Hell of a Summer," premiered this April and made back its budget, per The Numbers. Wolfhard has also become a successful voice actor. He voiced Pugsley in the animated "Addams Family" movie, which also made around $200 million (though he was recast for the 2021 sequel), and voiced Candlewick in 2021's " Guillermo del Toro's Pinocchio," which went on to win best animated feature at the Academy Awards. It's a wonder that Wolfhard also has time for a career as a musician. From 2017 to 2019, he was the lead singer of the band Calpurnia. He then joined the band The Aubreys, which released its debut album in 2021. On June 6, Wolfhard will release his debut solo album called "Happy Birthday." He's going on a mini-tour to support it during the month. 4. Joe Keery At last, we've come to Keery, aka Steve " The Hair" Harrington. Steve began the show as one of the mean popular kids, but has gone through a heartwarming transformation to become a fan favorite. Also, remember that baseball bat with the nails in it? Swoon. Keery was 24 when the show started airing, and now he's 33, the oldest of the main "kids" cast. His career has taken off since then. He was the lead of the 2020 black comedy/horror film "Spree," starred in "Free Guy" and "Pavements," and has an upcoming film co-starring Liam Neeson, Lesley Manville, and Vanessa Redgrave called "Cold Storage." He also had a main role in the fifth season of the anthology series " Fargo." But where Keery's edge lies is his music. While his costars have semi-successful musical careers, Keery (as his alter ego Djo) has had real success. His song "End of Beginning" was a bona fide hit in 2024, peaking at No. 11 on the Hot 100 chart, and received Billboard Music Award and Brit Award nominations. His 2025 album, "The Crux," peaked at No. 10 on the US Rock chart and No. 50 on the Billboard 200. The song "Charlie's Garden " is dedicated to his "Stranger Things" costar and friend Charlie Heaton. While Keery doesn't have a personal Instagram, he does have one as Djo, which has 1.4 million followers. He'll be touring through October 2025. 3. Sadie Sink Sink, 23, joined "Stranger Things" in season two as Max Mayfield, the new kid in Hawkins and a tomboy able to keep up with Mike and his friends, when she was 14. She eventually develops a close friendship with Eleven and begins dating Lucas in season three. Max was one of the biggest parts of season four. A pivotal scene in which she escapes the Upside Down helped bring the 1985 Kate Bush song " Running Up That Hill" back to the top of the charts, peaking at No. 3 on the Hot 100. Since joining "Stranger Things," Sink starred in the two Netflix horror films: "Fear Street 1978" and "Fear Street 1666." She also starred in the 2022 Oscar-winning film "The Whale," which earned her a Critics' Choice Award nomination. She began starring in the Broadway play "John Proctor Is the Villain" in 2025, which earned her a Tony Award nomination for best actress in a play. Sink is rumored to have an undisclosed role in the 2026 film "Spider-Man: Brand New Day," per Deadline. Now, we can't talk about Sink without mentioning her role as, essentially, the Taylor Swift self-insert role in " All Too Well: The Short Film," the music video for the 10-minute version of "All Too Well." If Swift picks you to play a fictional version of herself, you know you've made it. 2. Joseph Quinn If you were on TikTok in the summer of 2022, it was impossible to miss the sound of Quinn's voice screaming for Chrissy to wake up. Quinn, 31, joined the cast in season four as a high school (super) senior named Eddie Munson, a heavy-metal-loving, Dungeons-and-Dragons-playing sweetie who bonds with Dustin. Quinn's this high on the list because, in the three years since he was on the show, his career has soared. Since last year, he's been in "A Quiet Place: Day One" (a hit), " Gladiator II" (another hit), " Warfare," and will play none other than the Human Torch in " The Fantastic Four: First Steps" in July. And that's not all. In addition to reprising his role in "Avengers: Doomsday," he was announced to be playing George Harrison in Sam Mendes' four-part Beatles movie extravaganza. Quinn has 5.6 million followers on Instagram — not bad for someone who only joined the app in 2022 to promote "Stranger Things." 1. Millie Bobby Brown We haven't really mentioned Eleven (as played by Brown) in this ranking, because it's hard to explain her character without sounding a bit out there. But here we go: Eleven is a young girl who escaped from a secret government lab after discovering she has immense psychic powers. Brown, 21, was easily the breakout star of the show. During Halloween 2016, that pink dress, blonde wig, fake nosebleed, and Eggo box were unavoidable. Brown was just 12 when "Stranger Things" premiered, and received back-to-back Emmy nominations before she was 16. Since then, she's appeared in "Godzilla: King of the Monsters" ($387 million worldwide) and "Godzilla vs. Kong" ($470 million worldwide). She's also starred and produced in four Netflix movies (" Enola Holmes," "Enola Holmes 2," "Damsel" and " The Electric State" — three of which were huge hits) and has another "Enola" film on the way. She's proven herself to be a savvy businesswoman. She was reportedly paid $10 million for " Enola Holmes 2," and Brown has founded three successful companies: Florence by Mills Beauty, Florence by Mills Coffee, and Florence by Mills Fashion. Her beauty brand is available at Ulta, while her coffee is on shelves at Walmart. Brown also proved just how famous she was when she married Jake Bongiovi (son of Jon Bon Jovi) in 2024 and their wedding made dozens of headlines. And in case all that hasn't convinced you, Brown is far and away the most followed person from the cast, with a staggering 63.8 million followers on Instagram.
Medscape
42 minutes ago
- Medscape
Jun 06 2025 This Week in Cardiology
Please note that the text below is not a full transcript and has not been copyedited. For more insight and commentary on these stories, subscribe to the This Week in Cardiology podcast , download the Medscape app or subscribe on Apple Podcasts, Spotify, or your preferred podcast provider. This podcast is intended for healthcare professionals only. In This Week's Podcast For the week ending June 6, 2025, John Mandrola, MD, comments on the following topics: Listener feedback on cardiac sarcoidosis, out-of-hospital cardiac arrest, less is more when it comes to post-stent antiplatelets, lipoprotein(a), and atrial fibrillation in HFpEF. Dr Riina Kandolin from Helsinki, Finland, writes via email that I should clarify some of my comments on the cardiac sarcoidosis (CS) paper I made last week. The paper I spoke about last week from a primarily Dutch and Minnesota group compared societal recommendations for an ICD vs cardiovascular magnetic resonance imaging (CMR) phenotyping in patients with suspected CS. The key word was 'suspected' CS. In that study, in the European Heart Journal , CMR phenotyping by (1) no late gadolinium enhancement (LGE) and normal EF, (2) no LGE and abnormal EF, (3) pathology-frequent LGE, and (4) pathology-rare LGE, performed better than professional society recommendations for ventricular tachycardia (VT). Dr Kandolin pointed me to an incredible Circulation EP paper from their group in Helsinki on 305 patients with either biopsy-proven CS (just under half) or highly suggestive by criteria. Right away, this is a different population because the first study looked at patients with distant sarcoidosis (say the lungs) and were evaluating for cardiac sarcoidosis while the second study, in Circulation EP this year, studied patients with proven CS. Two main points of difference arise. In patients with true CS, all have pathology-frequent LGE. So it does not distinguish risk. Rather, the Finnish group showed that it was the degree (and somewhat the distribution) of LGE that predicts sudden death and VT. They found that myocardial LGE making up >9.9% of left ventricular (LV) mass or affecting >6 LV segments may suggest prognostically significant LV involvement and a high risk of sudden cardiac death (SCD). This analysis and its implications bear similarities to what we do for hypertrophic cardiomyopathy (HCM). Namely, in HCM, there is a risk score that corresponds to a yearly risk of VT. If th 5-year threshold reaches >6% for sudden cardiac death, then an ICD is recommended. ESC recommends a similar risk score prediction for laminopathies as well. ICDs for criteria above a risk threshold. The Finnish authors therefore suggest in their discussion that their CMR findings could have clinical relevance. Quote: In patients who have no other guideline-based class I or IIa indications, implantation could be considered if LGE mass is >9.9% by the full-width at half-maximum method or the LGE involves >6 LV segments. Less extensive LGE predicted a 5-year SCD/VT rate <7% with an SCD risk of 0.6 per 100 patient-years, and in these patients other EP studies or close surveillance with repeated risk assessments could be discussed at shared decision-making . If you care about CS and risk stratification, this is an excellent paper. It's worthy of a bookmark. I appreciate the feedback because I learned a lot. My one comment — and this is not at all a criticism of the paper (or papers) — but as a doctor I struggle with these risk thresholds. Say in HCM, what if the 5 year-risk is 5% not 6%. Or in this case of CS, the LGE mass is 7% not 9.9%? The dichotomization of implantable cardioverter-defibrillator (ICD) or no ICD of continuous variables makes me nervous when the outcome is surviving sudden death because you have an ICD. I realize it would be unwise to place ICDs in all patients, including low-risk people, because of ICD harm, but not having an ICD is also a risk. I don't know the answer and perhaps there never will be an answer to finding the ideal patient for an ICD, but HCM and CS are clearly different from RCT-based heart failure (HF) criteria. In HF, we have entry criteria from trials — albeit old trials. Sort of. We used to be able to say that if you are like a MADIT-2 patient, you have a 30% lower mortality with an ICD compared to no ICD. The modern problem is that medical therapy is a lot better, and that 30% benefit may be a lot less. By the way — that is why if you practice in Europe, you should be participating in PROFID EHRA trial of ICD vs no ICD in ICM. One practical comment from my experience is that if a CS patient has heart block and you are implanting hardware, it seems wise to strongly consider an ICD if the LGE is even close to the threshold. The listener feedback is great. I learn a ton from it. Thank you. The American Heart Association sent me two emails yesterday regarding their efforts to increase awareness of bystander CPR. One was a National Football League player named Justin Reid who is leading an effort; the other email said the Atlanta Falcons are teaming up with the AHA to equip players and coaches with the lifesaving CPR (cardiopulmonary) skills during National CPR and AED (automated external defibrillator) Week. The second note is that Circulation: Outcomes published a paper today from a group at Mid-America finding that resuscitation practices for out-of-hospital cardiac arrest (OHCA) differ by geographies. Namely, compared to White catchment areas, communities serving Black and Hispanic have lower rates of OHCA survival. Of course, the causes could be a lot of things, but the research team noted that in Black/Hispanic areas, first responders were less likely to recognize cardiac arrest, police were less likely to respond to a cardiac arrest, and patients were less likely to be defibrillated. Basically, community-level quality of OHCA was less than what it is White catchment areas. And this may explain the differences in survival. I think it explains some of the differences. But OHCA survival rates are complicated, and differences could also be due to severity of disease. My point in highlighting OHCA is that it's one of the highest value interventions in all of medicine. I have spent many hours on this podcast discussing new treatments with marginal benefit. Bystander CPR and an adequate EMS system is hugely valuable. Why? Because only 10% of patients with OHCA in the US survive. Ventricular fibrillation (VF) without CPR or an automated external defibrillator (AED) occurring out of the hospital is nearly 100% deadly. A VF patient depends on the knowledge and availability of his or her neighbors. Since survival is so bad, any tick up is likely highly cost effective. Bystander CPR and public AEDs are nearly free of risk — it's all benefit. I know OHCA care isn't as exciting as the newest ablation catheter, or stent, or new drug, but it's surely a lot higher in value than either of these things. A new tricuspid valve clip or more AEDs in your city? I'd go with the latter every time. So good on the AHA — and the NFL. The other thing I love about promoting OHCA is that it brings communities together for an obviously great and totally uncontroversial cause. Is a Year of Dual Antiplatelet Therapy Magical Thinking? I hesitate to delve into this topic because it is perhaps the most confusing in all of cardiology. But I will, because yet another study finds that 'less is more.' This seems too simple to state, but the idea is that having a metal cage propping open a coronary lesion is neither a fix nor is it free. Metal in the coronary attracts platelets and then clots can form. Stent thrombosis is a medicalized jargon, but it's a terrible outcome because you go from 0% blockage to 100% blockage. The good news is that the body eventually (and usually) forms a layer around the stent protecting it from the circulating platelets. This we call, and, jargon-wise it is a whopper, endothelialization. The problem of course is that antiplatelet drugs are also not free — blocking platelets increases the risk of major bleeding in the gut, kidneys, and brain. So, the quest — and it is a quest — is to find the Goldilocks recipe for preventing thrombotic or clotting events (such as myocardial infarction) with the lowest rate of bleeding. The usual regimen is to use two antiplatelet drugs (aspirin and either clopidogrel or ticagrelor or prasugrel) for a period before switching to single antiplatelet. Perhaps you can see the complexity already. There are four antiplatelet drugs of varying intensity; and there are near-infinite ways to break up time after the stent, and different types of patients. There's acute coronary syndrome (ACS) vs stable coronary artery disease (CAD) patients; there's high-bleeding risk and not-high-bleeding risk patients; and then there are different stents. You start multiplying and you get about a quadrillion different ways to do antiplatelet drugs. Today I will tell you about one recent trial — but know that there are many. The South Korean trial was called 4D-ACS. It was a comparison of two prasugrel-based strategies in about 650 patients who had PCI and stent during an ACS: one group gets one-month of dual antiplatelet therapy (DAPT) (aspirin 100 mg + prasugrel 10 mg, except the prasugrel dose is adjusted to 5 mg for age>75 or body weight < 60 kg vs the control arm: 12 month of DAPT with aspiring 100 mg and prasugrel 5 mg. The primary endpoint is called NACE. Not MACE , but NACE — or net adverse clinical events: death, myocardial infarction (MI), stroke, ischemia-driven revascularization and bleeding. Bleeding also has 5 different grades. This trial measured types 2-5, so minor bleeding was not included. The results: NACE occurred in 4.9% of the 1-month DAPT group and 8.8% of the 12-month DAPT group. The trial was a non-inferiority comparison. This is a good use of non-inferiority. Why? Because the short duration is very much less intense than the standard 12-month DAPT regimen. If it was just as good, it would be a win. Indeed the 4.9% vs 8.8% easily made non-inferiority and in fact with a hazard ratio [HR] of 0.51; 95% CI: 0.27-0.95; P = .034), it also made superiority. The driver of the lower NACE was a 77% lower rate of bleeding in the short duration DAPT arm: 1.2% vs 5.5%. There were almost no differences in thrombotic events such as MI, stroke, ischemia-driven revascularization. I cover this study because it is such a clear result. If using prasugrel, a one-month DAPT regimen is surely better than 12-month DAPT. You would think it's clear now, but it is surely not. First of all, all patients were Korean, and Asians may respond differently to antiplatelets. Second, the study used a type of stent that is not used in the US. Third, what about 1-month DAPT vs 3 months? What about combos of different antiplatelets. Like aspirin/clopidogrel vs clopidogrel. In general, the trend of late is for shorter courses of DAPT. But my solution in real life is to use one of the most important tools in all of medicine: phone-a-friend. I call my interventional cardiology colleague and ask what they think. They've done the stent and a bifurcation stent in the proximal LAD is going to be different from a mid-circumflex lesion. Perhaps I can make these general statements: ACS patients generally require longer DAPT duration (12 months) due to higher thrombotic risk Non-ACS patients most likely can safely use shorter DAPT durations (6 months for DES. Patients with high bleeding risk may benefit from abbreviated DAPT (1-3 months) regardless of presentation P2Y12 monotherapy after initial DAPT period shows promise for reducing bleeding while maintaining efficacy An individual risk assessment may prove helpful in guiding duration and intensity of DAPT. Final comment: if you are having an ST-elevation myocardial infarction (STEMI), you want a stent done fast. If you have chronic CAD, medical therapy first avoids the entire issue of deciding on the combination of antiplatelets. Sadly, this doesn't happen often enough in many places in the US. JAMA Cardiology has published an interesting study looking at the value (or lack of value) in adding Lp(a) into the new PREVENT equation. The first thing to say is that I covered the AHA's PREVENT equation in August of last year. Proponents of PREVENT say it's better than the standard PCE — which outputs 10-year risk of atherosclerotic events. Of course, the proponents of PREVENT don't just say it's better. PREVENT has been validated in observational datasets. PREVENT differs from the pooled cohort equation because it incorporates kidney function, statin use, social determinants of health and removes the race category. It also starts at a younger age. The most provocative aspect of PREVENT is that it simultaneously is felt to be more accurate, but it lowers estimates of CV risk and lowers the number of statin-eligible people. Gulp. Double gulp. Anyways, the question of the JAMA Cardiology study was whether the PREVENT equation can be made better by adding Lp(a) — which as you probably know is mostly genetically determined and, when elevated, is strongly associated with higher risk of CV events. Since race is removed from PREVENT and race can bear on Lp(a), adding it could be very important. Here is that they did. Two databases — UK biobank and MESA. This was big, big data. Both databases have long-term follow-up. Individuals in the database were put into 4 categories: low risk (5%), borderline (5%-7.5%), intermediate (7.5%-20%), and high risk (> 20%) Then they measured 10-year event rates and correlated it with Lp(a) levels overall and by risk category. Of course they do adjustments for age and sex. The main endpoint is the net reclassification improvement or NRI, which is complicated. Let me try to explain: NRI measures how well a new risk prediction model reclassifies people compared to an old model, but it does this by tracking movements in both directions and netting them out. The NRI splits reclassification into events (people who actually had the outcome) and non-events (people who didn't). For each group, it calculates: Proportion who moved up in risk categories minus the proportion who moved down This gives you a net movement figure for each group. The problem comes in relative vs absolute differences. You see this in the NRI studies of coronary artery calcium (CAC) where, when you consider absolute numbers, more people don't have events and are actually misclassified using NRI. I asked the AI tool Claude about this — because Claude helps — and Claude calls this 'The Conceptual Trap,' and I think it's worth talking about. Claude says that people often interpret NRI as "20% improvement in classification" when it's really "20% net improvement after accounting for movements in both directions." The absolute amount of reclassification — which tells you how much the models actually disagree — gets hidden in this netting process. In this study, they measured NRI both categorically — that is, how many moved into a different risk category based on Lp(a) (ie, going from borderline risk to intermediate risk) — and they also measured the NRI category-free (which is simply whether the patient moved up or down in risk at all). They differed — a lot. The category-free NRI for atherosclerotic events using Lp(a) was about .06 (or 6%). Now, the categorical NRI was 10 times lower — at 0.6% The way I would try to translate that is to say that adding Lp(a) reclassifies about 6% of people on a net basis for CV risk, but it is far less valuable for moving people between low, borderline, intermediate and high-risk categories. Here it was less than 1%. Now, the study did something else that is perhaps somewhat useful. They looked at subgroups of people who may get more reclassification. They found that adding Lp(a) resulted in slightly more reclassification for borderline risk and low risk people. But I have to say the differences are quite modest. For instance, the NRI for low-risk CHD prediction was 10% vs 7.5% for intermediate risk. 10% vs 7.5% — it doesn't seem like a big difference. This is a nice effort. Adding Lp(a) helps a little with prediction. A low-risk person who has an Lp(a) may want to take statins. A borderline person with a low Lp(a) may pass. But here's the thing, and I feel it's the same with CAC. I've seen patients for nearly 30 years in middle America, and the vast majority, perhaps 90% of people cannot conceptualize the difference between 7% and 9% vs 13% risk of 10-year events. I've had lipids done recently and I am borderline risk. And I can't really conceptualize 10-year risk of a nonfatal event. Maybe you can. Two reasons I struggle. One is that philosophically, I think much of disease and health is good and bad luck. As in…stuff happens. The second reason I struggle with 10-year risk prediction is relative to Ukraine attacking Russia's planes and the threat of World War III: how much worry should I place in whether my nonfatal CV risk is 7% without Lp(a) vs 9% with Lp(a)? I come back to my bottom-line when it comes to prevention: there are maximizers who want to do everything. For them, Lp(a) seems useless because they are already on aggressive lipid lowering. There are minimizers who aren't taking pills regardless. And for these patients, Lp(a) is also useless. So, for the few who sweat the details, fine — add Lp(a) to the mix. Publishing in EuroPace , a group of prominent researchers re-analyzed the TOPCAT Americas trial looking at the role of AF in predicting bad outcomes in patients with heart failure with preserved ejection fraction (HFpEF). Recall that TOPCAT is one of the most important trials in cardiology. Sadly, it was marred by data irregularities from Russia and Georgia. TOPCAT was spironolactone vs placebo in HFpEF. The hazard ratio (HR) was 0.89 for the composite primary of death, cardiac arrest, or heart failure hospitalization (HHF). The 11% reduction did not reach statistical significance. But all-cause death was 22% in the Americas and only 8% in Russia/Georgia, and the drug had little effect in that region. Further metabolic studies found that a third of patients supposedly randomized to spironolactone had undetectable metabolites. Excluding Russia and Georgia, TOPCAT was positive with a HR of 0.82 and a confidence interval of 0.69-0.98. I think this is a really important point. Ok, now to the EuroPace paper. The problem with studying HFpEF is it is diverse condition — unlike HFrEF. The authors, mostly EP docs, were interested in AF effects in HFpEF. Specifically, whether AF is simply a marker for advanced CV disease or is it an independent risk factor. They made two groups: Study patients who had AF before or at study entry. This was the 'any AF' group. Study patients with ongoing AF who had it at entry. Then they propensity-matched patients with no AF and looked at outcomes. I know, it's pretty easy to predict what will happen. Before I tell you the results, I hope you are thinking: small, hyperdynamic, noncompliant left ventricles are not going to do well with losing the atrial kick when AF occurs. The primary outcome of these comparisons was CV mortality. About 580 patients in TOPCAT who had any AF and 400 had ongoing AF. And they found that: Any AF was associated with a statistically significant increase in CV hospitalization, HHF, and progression of HF. Any AF, however, was not associated with an increased risk of sudden death. Ongoing AF was associated significantly with CVD, pump failure death, CV hospitalizations, and HHF. It was interesting to me that neither any AF or ongoing AF was not strongly associated with sudden death. AF seemed to associate mostly with progression of HF or pump failure. This paper has a lot of complicated comparisons, but I think it can be summarized as AF is a bad thing to have with underlying HFpEF. The question of course, the clinical question, is how to modify this problem with therapy. My first recommendation is to phone-a-friend: your EP colleague. I can't give you a generic right answer because there isn't one. HFpEF patients often have serious comorbidities that have to be considered, things like polypharmacy and CKD and valvular HD and frailty. Maybe antiarrhythmic drugs are the right answer. Maybe ablation. And underused in some places is the 'pace and ablate' strategy. We see a lot more HFpEF these days, because people live longer and with more chronic illness. When AF occurs, it's serious. Take Mr. Rogers' advice and realize that we all need helpers in our lives, and please: call your EP friends.
