Exaggerated systolic hypertensive response to exercise predicts cardiovascular events: a systematic review and meta-analysis

INTRODUCTION

The pathophysiology of exaggerated systolic hypertensive response to exercise (SHRE) is not fully understood, with contradictory data on its role in predicting cardiovascular (CV) events.

OBJECTIVES

The aim of this review and meta‑analysis was to assess the association of SHRE with CV clinical outcomes in healthy normotensive individuals.

PATIENTS AND METHODS

We searched PubMed (MEDLINE), Cochrane Library, RefWorks, and Google Scholar to identify clinical studies that reported data on CV event rates and outcomes for patients with SHRE on exercise stress testing. Sensitivity and specificity analysis for assessing the diagnostic accuracy of the SHRE cutoff associated with CV events was estimated using hierarchical summary receiver operating characteristic analysis.

RESULTS

We included 8 studies with 47 188 participants and a median follow‑up of 19.3 years. Exaggerated SHRE was found in patients with composite events (CV mortality and coronary artery disease; hazard ratio [HR], 1.363; 95% CI, 1.135-1.604; P <0.001), in those with coronary artery events (HR, 1.532; 95% CI, 1.240-1.893; P <0.001), and in those with CV mortality (HR, 1.286; 95% CI, 1.075-1.539; P =0.006), as compared with individuals with normal response. An exercise systolic blood pressure of 196 mm Hg predicted CV events with a sensitivity of 62% (54%-69%) and specificity of 75% (60%-86%), with a positive likelihood ratio of less than 3 and a strong correlation (r = -0.71).

CONCLUSIONS

Our study supports the clinical relevance of exaggerated SHRE as a predictor of composite and individual CV clinical outcome. These findings should be considered as thought‑provoking evidence for better stratification and, consequently, for optimal management of this high‑risk population.

Association of statin use and clinical outcomes in heart failure patients: a systematic review and meta-analysis

BACKGROUND

The role of statins in patients with heart failure (HF) of different levels of left ventricular ejection fraction (LVEF) remains unclear especially in the light of the absence of prospective data from randomized controlled trials (RCTs) in non-ischemic HF, and taking into account potential statins' prosarcopenic effects. We assessed the association of statin use with clinical outcomes in patients with HF.

METHODS

We searched PubMed, EMBASE, Scopus, Google Scholar and Cochrane Central until August 2018 for RCTs and prospective cohorts comparing clinical outcomes with statin vs non-statin use in patients with HF at different LVEF levels. We followed the guidelines of the 2009 PRISMA statement for reporting and applied independent extraction by multiple observers. Meta-analyses of hazard ratios (HRs) of effects of statins on clinical outcomes used generic inverse variance method and random model effects. Clinical outcomes were all-cause mortality, cardiovascular (CV) mortality and CV hospitalization.

RESULTS

Finally we included 17 studies (n = 88,100; 2 RCTs and 15 cohorts) comparing statin vs non-statin users (mean follow-up 36 months). Compared with non-statin use, statin use was associated with lower risk of all-cause mortality (HR 0.77, 95% confidence interval [CI], 0.72-0.83, P < 0.0001, I2 = 63%), CV mortality (HR 0.82, 95% CI: 0.76-0.88, P < 0.0001, I2 = 63%), and CV hospitalization (HR 0.78, 95% CI: 0.69-0.89, P = 0.0003, I2 = 36%). All-cause mortality was reduced on statin therapy in HF with both EF < 40% and ≥ 40% (HR: 0.77, 95% Cl: 0.68-0.86, P < 0.00001, and HR 0.75, 95% CI: 0.69-0.82, P < 0.00001, respectively). Similarly, CV mortality (HR 0.86, 95% CI: 0.79-0.93, P = 0.0003, and HR 0.83, 95% CI: 0.77-0.90, P < 0.00001, respectively), and CV hospitalizations (HR 0.80 95% CI: 0.64-0.99, P = 0.04 and HR 0.76 95% CI: 0.61-0.93, P = 0.009, respectively) were reduced in these EF subgroups. Significant effects on all clinical outcomes were also found in cohort studies' analyses; the effect was also larger and significant for lipophilic than hydrophilic statins.

CONCLUSIONS

In conclusion, statins may have a beneficial effect on CV outcomes irrespective of HF etiology and LVEF level. Lipophilic statins seem to be much more favorable for patients with heart failure.

Compromised left atrial function and increased size predict raised cavity pressure: a systematic review and meta-analysis

AIM

This meta-analysis assesses left atrial (LA) cavity and myocardial function measurements that predict pulmonary capillary wedge pressure (PCWP).

METHODS

PubMed-MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Central Registry were searched up to December 2018 for studies on the relationship of LA diameter, LA indexed volume (LAVI max, LAVI min), peak atrial longitudinal (PALS), peak atrial contraction (PACS) strain and total emptying fraction (LAEF) with PCWP. Eighteen studies with 1343 patients were included. Summary sensitivity and specificity (with 95% CI) for evaluation of diagnostic accuracy and the best cut-off values for different LA indices in predicting raised PCWP were estimated using summary receiver operating characteristic analysis.

RESULTS

The pooled analysis showed association between PCWP and LA diameter: Cohen's d = 0·87, LAVI max: d = 0·92 and LAVI min: d = 1·0 (P<0·001 for all). A stronger correlation was found between PCWP and PALS: d = 1·26, and PACS: d = 1·62, total EF d = 1·22 (P<0·0001 for all). PALS ≤19% had a summary sensitivity of 80% (65-90) and summary specificity of 77% (52-92), positive likelihood ratio (LR+) 3·74, negative likelihood ratio (LR-) <0·25 and DOR > 15·1 whereas LAVI ≥34 ml m^-2 had summary sensitivity of 75% (55-89) and summary specificity 77% (57-90), with LR+ >3, LR- 0·32 and DOR >10·1.

CONCLUSIONS

Compromised LA myocardial function and increased size predict raised cavity pressure. These results should assist in optimum follow-up of patients with fluctuating LA pressure.

Left atrial compliance index predicts exercise capacity in patients with heart failure and preserved ejection fraction irrespective of right ventricular dysfunction

BACKGROUND AND AIM

Predictors of exercise capacity in heart failure (HF) with preserved ejection fraction (HFpEF) remain of difficult determination. The aim of this study was to identify predictors of exercise capacity in a group of patients with HFpEF and right ventricle (RV) dysfunction METHODS: In 143 consecutive patients with HFpEF (age 62 ± 9 years, LV EF ≥45) and 41 controls, a complete echocardiographic study was performed. In addition to conventional measurements, LA compliance was calculated using the formula: [LAV max - LAV min/LAV min × 100]. Exercise capacity was assessed using the six-minute walking test (6-MWT). Tricuspid annular plane systolic excursion (TAPSE) < 1.7 cm was utilized to categorize patients with RV dysfunction (n = 40) from those with maintained RV function (n = 103).

RESULTS

Patients with RV dysfunction were older (P = 0.002), had higher NYHA class (P = 0.001), higher LV mass index (P = 0.01), reduced septal and lateral MAPSE (all P < 0.001), enlarged LA (P = 0.001) impaired LA compliance index (P < 0.001) and exhibited a more compromised 6-MWT (P = 0.001). LA compliance index correlated more closely with 6-MWT (r = 0.51, P < 0.001) compared with the other LA indices (AP diameter, transverse diameter and volume indexed; r = -0.30, r = -0.35 and r = -0.38, respectively). In multivariate analysis, LA compliance index <60% was 88% sensitive and 61% specific (AUC 0.80, CI = 0.67-0.92 P = 0.001) in predicting exercise capacity.

CONCLUSION

An impairment in LA compliance was profound in patients with HFpEF and RV dysfunction and seems to be most powerful independent predictor of limited exercise capacity.

The Role of Nutraceuticals in Statin Intolerant Patients

Statins are the most common drugs administered for patients with cardiovascular disease. However, due to statin-associated muscle symptoms, adherence to statin therapy is challenging in clinical practice. Certain nutraceuticals, such as red yeast rice, bergamot, berberine, artichoke, soluble fiber, and plant sterols and stanols alone or in combination with each other, as well as with ezetimibe, might be considered as an alternative or add-on therapy to statins, although there is still insufficient evidence available with respect to long-term safety and effectiveness on cardiovascular disease prevention and treatment. These nutraceuticals could exert significant lipid-lowering activity and might present multiple non-lipid-lowering actions, including improvement of endothelial dysfunction and arterial stiffness, as well as anti-inflammatory and antioxidative properties. The aim of this expert opinion paper is to provide the first attempt at recommendation on the management of statin intolerance through the use of nutraceuticals with particular attention on those with effective low-density lipoprotein cholesterol reduction.

Complete revascularization for patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease: a meta-analysis of randomized trials

INTRODUCTION

Despite the recent findings in randomized clinical trials (RCTs) with limited sample sizes and the updates in clinical guidelines, the current available data for the complete revascularization (CR) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) at the time of primary percutaneous coronary intervention (PCI) are still contradictory.

AIM

The aim of this meta-analysis of the existing RCTs was to assess the efficacy of the CR versus revascularization of infarct-related artery (IRA) only during primary PCI in patients with STEMI and multivessel disease (MVD).

PATIENTS AND METHODS

We searched PubMed, MEDLINE, Embase, Scopus, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases aiming to find RCTs for patients with STEMI and MVD which compared CR with IRA-only. Random effect risk ratios (RRs) were calculated for efficacy and safety outcomes.

RESULTS

Ten RCTs with 3291 patients were included. The median follow-up duration was 17.5 months. Major adverse cardiac events (RR=0.57; 0.43-0.76; P<0.0001), cardiac mortality (RR=0.52; 0.31-0.87; P=0.014), and repeat revascularization (RR=0.50; 0.30-0.84; P=0.009) were lower in CR compared with IRA-only strategies. However, there was no significant difference in the risk of all-cause mortality, recurrent nonfatal myocardial infarction, stroke, major bleeding events, and contrast-induced nephropathy.

CONCLUSION

For patients with STEMI and MVD undergoing primary PCI, the current evidence suggests that the risk of major adverse cardiac events, repeat revascularization, and cardiac death is reduced by CR. However, the risk for all-cause mortality and PCI-related complications is not different from the isolated culprit lesion-only treatment. Although these findings support the cardiac mortality and safety benefit of CR in stable STEMI, further large trials are required to provide better guidance for optimum management of such patients.

Echo- and B-Type Natriuretic Peptide-Guided Follow-Up versus Symptom-Guided Follow-Up: Comparison of the Outcome in Ambulatory Heart Failure Patients

Recent European Society of Cardiology and American Heart Association/American College of Cardiology Guidelines did not recommend biomarker-guided therapy in the management of heart failure (HF) patients. Combination of echo- and B-type natriuretic peptide (BNP) may be an alternative approach in guiding ambulatory HF management. Our aim was to determine whether a therapy guided by echo markers of left ventricular filling pressure (LVFP), lung ultrasound (LUS) assessment of B-lines, and BNP improves outcomes of HF patients. Consecutive outpatients with LV ejection fraction (EF) ≤ 50% have been prospectively enrolled. In Group I (n=224), follow-up was guided by echo and BNP with the goal of achieving E-wave deceleration time (EDT) ≥ 150 ms, tissue Doppler index E/e' < 13, B-line numbers < 15, and BNP ≤ 125 pg/ml or decrease >30%; in Group II (n=293), follow-up was clinically guided, while the remaining 277 patients (Group III) did not receive any dedicated follow-up. At 60 months, survival was 88% in Group I compared to 75% in Group II and 54% in Group III (χ ² 53.5; p < 0.0001). Survival curves exhibited statistically significant differences using Mantel-Cox analysis. The number needed to treat to spare one death was 7.9 (Group I versus Group II) and 3.8 (Group I versus Group III). At multivariate Cox regression analyses, major predictors of all-cause mortality were follow-up E/e' (HR: 1.05; p=0.0038) and BNP >125 pg/ml or decrease ≤30% (HR: 4.90; p=0.0054), while BNP > 125 pg/ml or decrease ≤30% and B-line numbers ≥15 were associated with the combined end point of death and HF hospitalization. Evidence-based HF treatment guided by serum biomarkers and ultrasound with the goal of reducing elevated BNP and LVFP, and resolving pulmonary congestion was associated with better clinical outcomes and can be valuable in guiding ambulatory HF management.

Adiponectin correlates with body mass index and to a lesser extent with left ventricular mass in dialysis patients

BACKGROUND

Adiponectin is a serum protein produced by adipose tissue which exerts anti-inflammatory, anti-diabetic and anti-atherosclerotic properties, hence is considered a cardio-protective marker. With the current uncertain role of adiponectin in dialysis patients to the aim of this study was to investigate its relationship with left ventricular (LV) structure and function in these patients.

METHODS

This study included 89 (age 56 ± 13 years, 43% male) patients treated with regular dialysis for > 6 months, and 55 control subjects with normal renal function. A complete two-dimensional, M-mode and tissue-Doppler echocardiographic study, and biochemical blood analyses, adiponectin and anthropometric parameters were obtainedon the same day.

RESULTS

Dialysis patients had lower body mass index (BMI) and lower body surface area (BSA) (p < 0.001 for both), lower waist/hips ratio (p = 0.005), higher LV mass index (LVMI, p < 0.001), higher adiponectin level (p < 0.001) and LV end-systolic volume (p = 0.003), lower LV ejection fraction (p = 0.006), longer isovolumic relaxation time (p < 0.001), lower mean LV strain (p = 0.002), larger left atrium volume (p = 0.022) and lower left atrium emptying fraction (p = 0.026), compared to controls. In dialysis patients, adiponectin correlated with waist circumference (r = -0.427, p < 0.001), BMI (r = -0.403, p < 0.001) and BSA (r = -0.480, p < 0.001), and to a lesser extent with LVMI (r = 0.296, p = 0.005), waist/hips ratio (r = -0.222, p = 0.037) and total cholesterol (r = -0.292, p = 0.013). But in controls, it correlated only modestly with age (r = 0.304, p = 0.024), hemoglobin (r = 0.371, p = 0.005), high density lipoprotein cholesterol (r = 0.315, p = 0.019) and LVMI (r = 0.277, p = 0.043).

CONCLUSIONS

It seems that in dialysis patients, adiponectin modest correlation with anthropometric measurements suggests an ongoing catabolic process rather than a change in ventricular function.

Quality of life questionnaire predicts poor exercise capacity only in HFpEF and not in HFrEF

BACKGROUND

The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is the most widely used measure of quality of life (QoL) in HF patients. This prospective study aimed to assess the relationship between QoL and exercise capacity in HF patients.

METHODS

The study subjects were 118 consecutive patients with chronic HF (62 ± 10 years, 57 females, in NYHA I-III). Patients answered a MLHFQ questionnaire in the same day of complete clinical, biochemical and echocardiographic assessment. They also underwent a 5 min walk test (6-MWT), in the same day, which grouped them into; Group I: ≤ 300 m and Group II: >300 m. In addition, left ventricular (LV) ejection fraction (EF), divided them into: Group A, with preserved EF (HFpEF) and Group B with reduced EF (HFrEF).

RESULTS

The mean MLHFQ total scale score was 48 (±17). The total scale, and the physical and emotional functional MLHFQ scores did not differ between HFpEF and HFpEF. Group I patients were older (p = 0.003), had higher NYHA functional class (p = 0.002), faster baseline heart rate (p = 0.006), higher prevalence of smoking (p = 0.015), higher global, physical and emotional MLHFQ scores (p < 0.001, for all), larger left atrial (LA) diameter (p = 0.001), shorter LV filling time (p = 0.027), higher E/e' ratio (0.02), shorter isovolumic relaxation time (p = 0.028), lower septal a' (p = 0.019) and s' (p = 0.023), compared to Group II. Independent predictors of 6-MWT distance for the group as a whole were increased MLHFQ total score (p = 0.005), older age (p = 0.035), and diabetes (p = 0.045), in HFpEF were total MLHFQ (p = 0.007) and diabetes (p = 0.045) but in HFrEF were only LA enlargement (p = 0.005) and age (p = 0.013. A total MLHFQ score of 48.5 had a sensitivity of 67% and specificity of 63% (AUC on ROC analysis of 72%) for limited exercise performance in HF patients.

CONCLUSIONS

Quality of life, assessment by MLHFQ, is the best correlate of exercise capacity measured by 6-MWT, particularly in HFpEF patients. Despite worse ejection fraction in HFrEF, signs of raised LA pressure independently determine exercise capacity in these patients.

Lipid-lowering nutraceuticals in clinical practice: position paper from an International Lipid Expert Panel

In recent years, there has been growing interest in the possible use of nutraceuticals to improve and optimize dyslipidemia control and therapy. Based on the data from available studies, nutraceuticals might help patients obtain theraputic lipid goals and reduce cardiovascular residual risk. Some nutraceuticals have essential lipid-lowering properties confirmed in studies; some might also have possible positive effects on nonlipid cardiovascular risk factors and have been shown to improve early markers of vascular health such as endothelial function and pulse wave velocity. However, the clinical evidence supporting the use of a single lipid-lowering nutraceutical or a combination of them is largely variable and, for many of the nutraceuticals, the evidence is very limited and, therefore, often debatable. The purpose of this position paper is to provide consensus-based recommendations for the optimal use of lipid-lowering nutraceuticals to manage dyslipidemia in patients who are still not on statin therapy, patients who are on statin or combination therapy but have not achieved lipid goals, and patients with statin intolerance. This statement is intended for physicians and other healthcare professionals engaged in the diagnosis and management of patients with lipid disorders, especially in the primary care setting.

Antithrombotic treatment tailoring and risk score evaluation in elderly patients diagnosed with an acute coronary syndrome

Age is an important prognostic factor in the outcome of acute coronary syndromes (ACS). A substantial percentage of patients who experience ACS is more than 75 years old, and they represent the fastest-growing segment of the population treated in this setting. These patients present different patterns of responses to pharmacotherapy, namely, a higher ischemic and bleeding risk than do patients under 75 years of age. Our aim was to identify whether the currently available ACS ischemic and bleeding risk scores, which has been validated for the general population, may also apply to the elderly population. The second aim was to determine whether the elderly benefit more from a specific pharmacological regimen, keeping in mind the numerous molecules of antiplatelet and antithrombotic drugs, all validated in the general population. We concluded that the GRACE (Global Registry of Acute Coronary Events) risk score has been extensively validated in the elderly. However, the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) bleeding score has a moderate correlation with outcomes in the elderly. Until now, there have not been head-to-head scores that quantify the ischemic versus hemorrhagic risk or scores that use the same end point and timeline (e.g., ischemic death rate versus bleeding death rate at one month). We also recommend that the frailty score be considered or integrated into the current existing scores to better quantify the overall patient risk. With regard to medical treatment, based on the subgroup analysis, we identified the drugs that have the least adverse effects in the elderly while maintaining optimal efficacy.

Hydrophilic vs lipophilic statins in coronary artery disease: A meta-analysis of randomized controlled trials

INTRODUCTION

Some available experimental studies have reported that hydrophilic statins might have advantages compared with lipophilic statins in patients with coronary artery disease (CAD). Therefore, we performed a meta-analysis of randomized controlled trials (RCTs) investigating the potential differences of lipophilic and hydrophilic statins in patients with CAD.

METHODS

We systematically searched selected electronic databases up to September 2016 to select RCTs, which compared clinical outcomes of hydrophilic vs lipophilic statins. Primary endpoints were cardiovascular (CV) events: major adverse cardiac events, myocardial infarction, cardiac revascularization, stroke, CV death, CV hospitalization, and all-cause mortality. Secondary endpoints were safety parameters: drug discontinuation, statin-associated muscle symptoms and alanine aminotransferase level increase.

RESULTS

A total of 11,697 patients from 11 RCTs, randomly allocated to lipophilic (n = 5736) or hydrophilic statins (n = 5961), with a mean follow-up 14 months, were included in the meta-analysis. In comparison with hydrophilic, the lipophilic statins showed similar risk reduction for major adverse cardiac events (relative risk = 0.969, 95% confidence interval [CI], 0.835-1.125, P = .682), myocardial infarction (0.880, 95% CI: 0.731-1.058, P = .174), CV death (0.757, 95% CI: 0.486-1.180, P = .219), and all-cause mortality (0.797, 95% CI: 0.590-1.075, P = .137), as well as cardiac revascularization, stroke, drug discontinuation, and statin-associated muscle symptoms. CV hospitalization was lower (0.789, 95% CI: 0.643-0.969, P = .024) and alanine aminotransferase elevation was higher (2.689, 95% CI: 1.841-3.954, P ≤ .001) in lipophilic than in hydrophilic-treated patients.

CONCLUSIONS

In conclusion, similarity between hydrophilic and lipophilic statins holds between various clinical CAD settings.

Different determinants of exercise capacity in HFpEF compared to HFrEF

BACKGROUND

Quality of life is as important as survival in heart failure (HF) patients. Controversies exist with regards to echocardiographic determinants of exercise capacity in HF, particularly in patients with preserved ejection fraction (HFpEF). The aim of this study was to prospectively examine echocardiographic parameters that correlate and predict functional exercise capacity assessed by 6 min walk test (6-MWT) in patients with HFpEF.

METHODS

In 111 HF patients (mean age 63 ± 10 years, 47% female), an echo-Doppler study and a 6-MWT were performed in the same day. Patients were divided into two groups based on the 6-MWT distance (Group I: ≤ 300 m and Group II: >300 m).

RESULTS

Group I were older (p = 0.008), had higher prevalence of diabetes (p = 0.027), higher baseline heart rate (p = 0.004), larger left atrium - LA (p = 0.001), longer LV filling time - FT (p = 0.019), shorter isovolumic relaxation time (p = 0.037), shorter pulmonary artery acceleration time - PA acceleration time (p = 0.006), lower left atrial lateral wall myocardial velocity (a') (p = 0.018) and lower septal systolic myocardial velocity (s') (p = 0.023), compared with Group II. Patients with HF and reduced EF (HFrEF) had lower hemoglobin (p = 0.007), higher baseline heart rate (p = 0.005), higher NT-ProBNP (p = 0.001), larger LA (p = 0.004), lower septal s', e', a' waves, and septal mitral annular plane systolic excursion (MAPSE), shorter PA acceleration time (p < 0.001 for all), lower lateral MAPSE, higher E/A & E/e', and shorter LVFT (p = 0.001 for all), lower lateral e' (p = 0.009), s' (p = 0.006), right ventricular e' and LA emptying fraction (p = 0.012 for both), compared with HFpEF patients. In multivariate analysis, only LA diameter [2.676 (1.242-5.766), p = 0.012], and diabetes [0.274 (0.084-0.898), p = 0.033] independently predicted poor 6-MWT performance in the group as a whole. In HFrEF, age [1.073 (1.012-1.137), p = 0.018] and LA diameter [3.685 (1.348-10.071), p = 0.011], but in HFpEF, lateral s' [0.295 (0.099-0.882), p = 0.029], and hemoglobin level [0.497 (0.248-0.998), p = 0.049] independently predicted poor 6-MWT performance.

CONCLUSIONS

In HF patients determinants of exercise capacity differ according to severity of overall LV systolic function, with left atrial enlargement in HFrEF and longitudinal systolic shortening in HFpEF as the the main determinants.

Left atrial changes in early stages of heart failure with preserved ejection fraction

BACKGROUND AND AIM

Increased left atrial (LA) mass was introduced as a compensatory mechanism in heart failure (HF) patients. Furthermore, atrial conduction time and LA emptying fraction is are deteriorated in HF with preserved ejection fraction (HFpEF). The aim of this study was to assess the early LA changes in HFpEF patients.

METHODS

In 79 consecutive patients with HFpEF (age 61±8 years, NYHA class I-III, LV EF ≥45%), a complete 2-dimensional, M-mode, and Doppler echocardiographic study was performed. According to the diastolic dysfunction (DD), patients were divided into three groups: Group I-29 healthy subjects (control group); Group II-HFpEF patients with mild DD; and Group III-HFpEF patients with moderate DD.

RESULTS

The LV mass was increased (P<.05), septal s', lateral s', septal and lateral MAPSE were decreased (P<.05, for all), E/e' ratio was increased (P<.001), LA mass and minimal volume were increased (P<.001, P<.05), LA emptying fraction was decreased (P<.05), and LA dyssynchrony was deteriorated (P<.05) in patients with mild DD compared to controls. These changes were of the same nature in patients with moderate LV DD.

CONCLUSIONS

In early stage of DD, in patients with HFpEF, in addition to LV hypertrophy and compromised LV longitudinal systolic function, the LA emptying fraction is reduced, LA mass and LAV min are increased and LA dyssynchrony is significant, despite normal LA dimensions. These findings suggest early LA function deterioration irrespective of normal cavity measurements, hence a need for optimum therapy.

Comparison of drug-eluting balloon versus drug-eluting stent treatment of drug-eluting stent in-stent restenosis: A meta-analysis of available evidence

BACKGROUND

In-stent restenosis (ISR) remains an important concern despite the recent advances in the drug-eluting stent (DES) technology. The introduction of drug-eluting balloons (DEB) offers a good solution to such problem.

OBJECTIVES

We performed a meta-analysis to assess the clinical efficiency and safety of DEB compared with DES in patients with DES-ISR.

METHODS

A systematic search was conducted and all randomized and observational studies which compared DEB with DES in patients with DES-ISR were included. The primary outcome measure-major adverse cardiovascular events (MACE)-as well as individual events as target lesion revascularization (TLR), stent thrombosis (ST), myocardial infarction (MI), cardiac death (CD) and all-cause mortality, were analyzed.

RESULTS

Three randomized and 4 observational studies were included with a total of 2052 patients. MACE (relative risk [RR]=1.00, 95% confidence interval (CI) 0.68 to 1.46, P=0.99), TLR (RR=1.15 [CI 0.79 to 1.68], P=0.44), ST (RR=0.37[0.10 to 1.34], P=0.13), MI (RR=0.97 [0.49 to 1.91], P=0.93) and CD (RR=0.73 [0.22 to 2.45], P=0.61) were not different between patients treated with DEB and with DES. However, all-cause mortality was lower in patients treated with DEB (RR=0.45 [0.23 to 0.87, P=0.019) and in particular when compared to only first generation DES (RR 0.33 [0.15-0.74], P=0.007). There was no statistical evidence for publication bias.

CONCLUSIONS

The results of this meta-analysis showed that DEB and DES have similar efficacy and safety for the treatment of DES-ISR.

Carotid plaque echogenicity predicts cerebrovascular symptoms: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Many reports have shown an association between hypoechoic (echolucent) carotid atherosclerotic plaques and unstable features. In this meta-analysis our aim was to determine the role of carotid plaque echogenicity in predicting future cerebrovascular (CV) symptoms.

METHODS

Electronic databases (PubMed, MEDLINE, EMBASE and Cochrane Center Register) up to September 2015 were systematically searched. Studies with ultrasound-based characterization of carotid artery plaque echogenicity and its association with focal neurological symptoms of vascular origin were eligible for analysis. In the meta-analysis, heterogeneity was measured using I(2) statistics and publication bias was evaluated using the Begg-Mazumdar test. In addition several comparisons between subgroups were performed.

RESULTS

Of 1387 identified reports, eight studies with asymptomatic patients and three studies with symptomatic patients were meta-analyzed. Pooled analysis showed an association between echolucent carotid plaques and future CV events in asymptomatic patients [relative risk 2.72 (95% confidence interval 1.86-3.96)] and recurrent symptoms in symptomatic patients [relative risk 2.97 (95% confidence interval 1.85-4.78)]. The association was preserved for all stenosis degrees in asymptomatic patients, whilst patients with echolucent plaques and severe stenosis were at higher risk of future events. Also, computer-assisted methods for assessment of carotid plaque echogenicity and studies analyzing ultrasound data collected after the year 2000 showed better prediction.

CONCLUSIONS

In asymptomatic and symptomatic patients, analysis of carotid plaque echogenicity could identify those at high risk of CV events.