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Twiner MJ, Hennessy J, Wein R, Levy PD. Nitroglycerin Use in the Emergency Department: Current Perspectives. Open Access Emerg Med 2022; 14:327-333. [PMID: 35847764 PMCID: PMC9278720 DOI: 10.2147/oaem.s340513] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022] Open
Abstract
Nitroglycerin, a fast-acting vasodilator, is commonly used as a first-line agent for angina in the emergency department and to manage chest pain due to acute coronary syndromes. It is also a treatment option for other disease states such as acute heart failure, pulmonary edema, and aortic dissection. Nitroglycerin is converted to nitric oxide, a potent vasodilator, in the body, leading to venodilation at lower dosages and arteriodilation at higher dosages that results in both preload and afterload reduction, respectively. Although nitroglycerin has historically been administered as a sublingual tablet and/or spray, it is often given intravenously in the emergency department as this enables titration to effect with predictable pharmacokinetics. In this review article, we outline the indications, mechanism of action, contraindications, and adverse effects of nitroglycerin as well as review relevant literature and make general recommendations regarding the use of nitroglycerin in the emergency department.
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Affiliation(s)
- Michael J Twiner
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA.,Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - John Hennessy
- College of Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Rachel Wein
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA.,Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
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Ko T, Yang CH, Mao CT, Kuo LT, Hsieh MJ, Chen DY, Wang CY, Lin YS, Hsieh IC, Chen SW, Hung MJ, Cherng WJ, Chen TH. Effects of National Hospital Accreditation in Acute Coronary Syndrome on In-Hospital Mortality and Clinical Outcomes. ACTA CARDIOLOGICA SINICA 2020; 36:416-427. [PMID: 32952351 DOI: 10.6515/acs.202009_36(5).20200421a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Acute coronary syndrome (ACS) is a life-threatening medical condition that accounts for an annual expenditure of more than $300 billion in the United States. Hospital accreditation has been shown to improve patient and hospital outcomes for various conditions. Objectives This study aimed to determine the benefits of hospital accreditation in patients with ACS. Methods This nationwide population-based cohort study used Taiwan's National Health Insurance Research Database from 1997 to 2011 (n = 249,354). Multivariable logistic regression was used to analyze the risk of in-hospital events among those treated in accredited and non-accredited hospitals, and to compare outcomes in hospitals before and after accreditation. The effect of accreditation on these events was also stratified by accreditation grade. Results A total of 823 hospitals were included, of which 2.4% were medical centers, 13.7% were regional hospitals, and 83.8% were district hospitals. The in-hospital mortality [odds ratio (OR), 0.82; 95% confidence interval (CI), 0.79-0.85; p < 0.001] and recurrent acute myocardial infarction (AMI) admission (OR, 0.81; 95% CI, 0.71-0.93; p = 0.003) rates were significantly lower in the after-accreditation group than in the before-accreditation group. There was a substantial and marked decrease in the in-hospital mortality rate after accreditation in 2008. Conclusions This cohort study demonstrated that ACS accreditation was associated with better in-hospital mortality and recurrent AMI admission rates in ACS patients.
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Affiliation(s)
- Ta Ko
- Division of Cardiology, Department of Internal Medicine, Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung; Chang Gung University College of Medicine, Taoyuan
| | - Chia-Hung Yang
- Division of Cardiology, Department of Internal Medicine, Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan
| | - Chun-Tai Mao
- Division of Cardiology, Department of Internal Medicine, Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung; Chang Gung University College of Medicine, Taoyuan
| | - Li-Tang Kuo
- Division of Cardiology, Department of Internal Medicine, Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung; Chang Gung University College of Medicine, Taoyuan
| | - Ming-Jer Hsieh
- Division of Cardiology, Department of Internal Medicine, Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan
| | - Dong-Yi Chen
- Division of Cardiology, Department of Internal Medicine, Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan
| | - Chao-Yung Wang
- Division of Cardiology, Department of Internal Medicine, Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan
| | - Yu-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi; Chang Gung University College of Medicine, Taoyuan
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan
| | - Shao-Wei Chen
- Department of Cardiac Surgery, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Jui Hung
- Division of Cardiology, Department of Internal Medicine, Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung; Chang Gung University College of Medicine, Taoyuan
| | - Wen-Jin Cherng
- Division of Cardiology, Department of Internal Medicine, Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan
| | - Tien-Hsing Chen
- Division of Cardiology, Department of Internal Medicine, Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung; Chang Gung University College of Medicine, Taoyuan
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3
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Le T, Paterson DI, Davies NM, Mackey JR. Development and validation of a compact on-person storage device (SMHeartCard) for emergency access to acetylsalicylic acid and nitroglycerin. CMAJ Open 2020; 8:E75-E82. [PMID: 32046972 PMCID: PMC7012633 DOI: 10.9778/cmajo.20190147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Guidelines recommend that patients with coronary artery disease (CAD) carry and immediately use acetylsalicylic acid (ASA) and sublingually administered nitroglycerin at the onset of chest pain; however, compliance with these recommendations is poor. We designed and tested a compact on-person storage device for these medications. METHODS We designed an airtight, light-proof and chemically inert holder to carry four 81-mg ASA tablets and three 0.3-mg Nitrostat (nitroglycerin, Pfizer) tablets. After establishing the temperatures ranges in wallets and pockets, we tested nitroglycerin dissolution and release of the stored Nitrostat tablets across a range of relevant temperatures and a variety of tablet enclosure systems. RESULTS Microcalorimeter thermal conduction studies as well as dissolution and release testing showed that nitroglycerin tablets were stable at temperatures ranging from -20°C to 60°C for 1 week. In testing up to 24 weeks, 0.3-mg Nitrostat tablets enclosed completely in polytetrafluoroethylene (PTFE) performed similarly to those stored in the manufacturer's borosilicate glass packaging across a wide range of temperatures relevant to on-person carriage. Real-world on-person testing for 24 weeks confirmed these results. Non-PTFE enclosures performed poorly. INTERPRETATION The PTFE enclosure with a PTFE-coated cap liner maintained long-term performance of 0.3-mg Nitrostat tablets under laboratory and real-world conditions. This storage device is now commercially available as the SMHeartCard to improve compliance and provide immediate access to emergency cardiac medications.
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Affiliation(s)
- Tyson Le
- Faculties of Pharmacy and Pharmaceutical Sciences (Le, Davies) and of Medicine and Dentistry (Paterson), University of Alberta; Alberta Health Services (Mackey), Cross Cancer Institute, Edmonton, Alta
| | - D Ian Paterson
- Faculties of Pharmacy and Pharmaceutical Sciences (Le, Davies) and of Medicine and Dentistry (Paterson), University of Alberta; Alberta Health Services (Mackey), Cross Cancer Institute, Edmonton, Alta
| | - Neal M Davies
- Faculties of Pharmacy and Pharmaceutical Sciences (Le, Davies) and of Medicine and Dentistry (Paterson), University of Alberta; Alberta Health Services (Mackey), Cross Cancer Institute, Edmonton, Alta
| | - John R Mackey
- Faculties of Pharmacy and Pharmaceutical Sciences (Le, Davies) and of Medicine and Dentistry (Paterson), University of Alberta; Alberta Health Services (Mackey), Cross Cancer Institute, Edmonton, Alta.
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4
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Safi S, Sethi NJ, Nielsen EE, Feinberg J, Gluud C, Jakobsen JC. Beta-blockers for suspected or diagnosed acute myocardial infarction. Cochrane Database Syst Rev 2019; 12:CD012484. [PMID: 31845756 PMCID: PMC6915833 DOI: 10.1002/14651858.cd012484.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiovascular disease is the number one cause of death globally. According to the World Health Organization, 7.4 million people died from ischaemic heart diseases in 2012, constituting 15% of all deaths. Acute myocardial infarction is caused by blockage of the blood supplied to the heart muscle. Beta-blockers are often used in patients with acute myocardial infarction. Previous meta-analyses on the topic have shown conflicting results ranging from harms, neutral effects, to benefits. No previous systematic review using Cochrane methodology has assessed the effects of beta-blockers for acute myocardial infarction. OBJECTIVES To assess the benefits and harms of beta-blockers compared with placebo or no intervention in people with suspected or diagnosed acute myocardial infarction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded and BIOSIS Citation Index in June 2019. We also searched the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, Turning Research into Practice, Google Scholar, SciSearch, and the reference lists of included trials and previous reviews in August 2019. SELECTION CRITERIA We included all randomised clinical trials assessing the effects of beta-blockers versus placebo or no intervention in people with suspected or diagnosed acute myocardial infarction. Trials were included irrespective of trial design, setting, blinding, publication status, publication year, language, and reporting of our outcomes. DATA COLLECTION AND ANALYSIS We followed the Cochrane methodological recommendations. Four review authors independently extracted data. Our primary outcomes were all-cause mortality, serious adverse events according to the International Conference on Harmonization - Good Clinical Practice (ICH-GCP), and major adverse cardiovascular events (composite of cardiovascular mortality and non-fatal myocardial infarction during follow-up). Our secondary outcomes were quality of life, angina, cardiovascular mortality, and myocardial infarction during follow-up. Our primary time point of interest was less than three months after randomisation. We also assessed the outcomes at maximum follow-up beyond three months. Due to risk of multiplicity, we calculated a 97.5% confidence interval (CI) for the primary outcomes and a 98% CI for the secondary outcomes. We assessed the risks of systematic errors through seven bias domains in accordance to the instructions given in the Cochrane Handbook. The quality of the body of evidence was assessed by GRADE. MAIN RESULTS We included 63 trials randomising a total of 85,550 participants (mean age 57.4 years). Only one trial was at low risk of bias. The remaining trials were at high risk of bias. The quality of the evidence according to GRADE ranged from very low to high. Fifty-six trials commenced beta-blockers during the acute phase of acute myocardial infarction and seven trials during the subacute phase. At our primary time point 'less than three months follow-up', meta-analysis showed that beta-blockers versus placebo or no intervention probably reduce the risk of a reinfarction during follow-up (risk ratio (RR) 0.82, 98% confidence interval (CI) 0.73 to 0.91; 67,562 participants; 18 trials; moderate-quality evidence) with an absolute risk reduction of 0.5% and a number needed to treat for an additional beneficial outcome (NNTB) of 196 participants. However, we found little or no effect of beta-blockers when assessing all-cause mortality (RR 0.94, 97.5% CI 0.90 to 1.00; 80,452 participants; 46 trials/47 comparisons; high-quality evidence) with an absolute risk reduction of 0.4% and cardiovascular mortality (RR 0.99, 95% CI 0.91 to 1.08; 45,852 participants; 1 trial; moderate-quality evidence) with an absolute risk reduction of 0.4%. Regarding angina, it is uncertain whether beta-blockers have a beneficial or harmful effect (RR 0.70, 98% CI 0.25 to 1.84; 98 participants; 3 trials; very low-quality evidence) with an absolute risk reduction of 7.1%. None of the trials specifically assessed nor reported serious adverse events according to ICH-GCP. Only two trials specifically assessed major adverse cardiovascular events, however, no major adverse cardiovascular events occurred in either trial. At maximum follow-up beyond three months, meta-analyses showed that beta-blockers versus placebo or no intervention probably reduce the risk of all-cause mortality (RR 0.93, 97.5% CI 0.86 to 0.99; 25,210 participants; 21 trials/22 comparisons; moderate-quality evidence) with an absolute risk reduction of 1.1% and a NNTB of 91 participants, and cardiovascular mortality (RR 0.90, 98% CI 0.83 to 0.98; 22,457 participants; 14 trials/15 comparisons; moderate-quality evidence) with an absolute risk reduction of 1.2% and a NNTB of 83 participants. However, it is uncertain whether beta-blockers have a beneficial or harmful effect when assessing major adverse cardiovascular events (RR 0.81, 97.5% CI 0.40 to 1.66; 475 participants; 4 trials; very low-quality evidence) with an absolute risk reduction of 1.7%; reinfarction (RR 0.89, 98% CI 0.75 to 1.08; 6825 participants; 14 trials; low-quality evidence) with an absolute risk reduction of 0.9%; and angina (RR 0.64, 98% CI 0.18 to 2.0; 844 participants; 2 trials; very low-quality evidence). None of the trials specifically assessed nor reported serious adverse events according to ICH-GCP. None of the trials assessed quality of life. We identified two ongoing randomised clinical trials investigating the effect of early administration of beta-blockers after percutaneous coronary intervention or thrombolysis to patients with an acute myocardial infarction and one ongoing trial investigating the effect of long-term beta-blocker therapy. AUTHORS' CONCLUSIONS Our present review indicates that beta-blockers for suspected or diagnosed acute myocardial infarction probably reduce the short-term risk of a reinfarction and the long-term risk of all-cause mortality and cardiovascular mortality. Nevertheless, it is most likely that beta-blockers have little or no effect on the short-term risk of all-cause mortality and cardiovascular mortality. Regarding all remaining outcomes (serious adverse events according to ICH-GCP, major adverse cardiovascular events (composite of cardiovascular mortality and non-fatal myocardial infarction during follow-up), the long-term risk of a reinfarction during follow-up, quality of life, and angina), further information is needed to confirm or reject the clinical effects of beta-blockers on these outcomes for people with or suspected of acute myocardial infarction.
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Affiliation(s)
- Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Naqash J Sethi
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Emil Eik Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
- Cardiology SectionDepartment of Internal MedicineSmedelundsgade 60HolbækDanmarkDenmark4300
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Christian Gluud
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
- University of Southern DenmarkDepartment of Regional Health Research, the Faculty of Health SciencesHolbaekDenmark
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Breda J, Wickramasinghe K, Peters DH, Rakovac I, Oldenburg B, Mikkelsen B, Shao R, Varghese C, Collins T, Wall K, Farrington J, Townsend N. One size does not fit all: implementation of interventions for non-communicable diseases. BMJ 2019; 367:l6434. [PMID: 31810904 DOI: 10.1136/bmj.l6434] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- João Breda
- WHO European Office for Prevention and Control of NCDs, Moscow, Russia
| | | | - David H Peters
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA
| | - Ivo Rakovac
- WHO European Office for Prevention and Control of NCDs, Moscow, Russia
| | - Brian Oldenburg
- WHO Collaborating Centre on Implementation Research for Prevention and Control of Noncommunicable Diseases, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Bente Mikkelsen
- Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Ruitai Shao
- World Health Organization, Geneva, Switzerland
| | | | - Téa Collins
- World Health Organization, Geneva, Switzerland
| | - Kristen Wall
- WHO European Office for Prevention and Control of NCDs, Moscow, Russia
| | - Jill Farrington
- Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe, Copenhagen, Denmark
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6
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Bucholz EM, Butala NM, Normand SLT, Wang Y, Krumholz HM. Association of Guideline-Based Admission Treatments and Life Expectancy After Myocardial Infarction in Elderly Medicare Beneficiaries. J Am Coll Cardiol 2017; 67:2378-2391. [PMID: 27199062 DOI: 10.1016/j.jacc.2016.03.507] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 02/29/2016] [Accepted: 03/08/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Guideline-based admission therapies for acute myocardial infarction (AMI) significantly improve 30-day survival, but little is known about their association with long-term outcomes. OBJECTIVES This study evaluated the association of 5 AMI admission therapies (aspirin, beta-blockers, acute reperfusion therapy, door-to-balloon [D2B] time ≤90 min, and time to fibrinolysis ≤30 min) with life expectancy and years of life saved after AMI. METHODS We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries hospitalized for AMI, with 17 years of follow-up. Life expectancy and years of life saved after AMI were calculated using Cox proportional hazards regression with extrapolation using exponential models. RESULTS Survival for recipients and non-recipients of the 5 guideline-based therapies diverged early after admission and continued to diverge during 17-year follow-up. Receipt of aspirin, beta-blockers, and acute reperfusion therapy on admission was associated with longer life expectancy of 0.78 (standard error [SE]: 0.05), 0.55 (SE: 0.06), and 1.03 (SE: 0.12) years, respectively. Patients receiving primary percutaneous coronary intervention (PCI) within 90 min lived 1.08 (SE: 0.49) years longer than patients with D2B times >90 min, and door-to-needle (D2N) times ≤30 min were associated with 0.55 (SE: 0.12) more years of life. A dose-response relationship was observed between longer D2B and D2N times and shorter life expectancy after AMI. CONCLUSIONS Guideline-based therapy for AMI admission is associated with both early and late survival benefits, and results in meaningful gains in life expectancy and large numbers of years of life saved in elderly patients.
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Affiliation(s)
- Emily M Bucholz
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Yale School of Medicine and Yale School of Public Health, New Haven, Connecticut
| | - Neel M Butala
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yun Wang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut; Section of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut.
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7
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Imberger G, Thorlund K, Gluud C, Wetterslev J. False-positive findings in Cochrane meta-analyses with and without application of trial sequential analysis: an empirical review. BMJ Open 2016; 6:e011890. [PMID: 27519923 PMCID: PMC4985805 DOI: 10.1136/bmjopen-2016-011890] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Many published meta-analyses are underpowered. We explored the role of trial sequential analysis (TSA) in assessing the reliability of conclusions in underpowered meta-analyses. METHODS We screened The Cochrane Database of Systematic Reviews and selected 100 meta-analyses with a binary outcome, a negative result and sufficient power. We defined a negative result as one where the 95% CI for the effect included 1.00, a positive result as one where the 95% CI did not include 1.00, and sufficient power as the required information size for 80% power, 5% type 1 error, relative risk reduction of 10% or number needed to treat of 100, and control event proportion and heterogeneity taken from the included studies. We re-conducted the meta-analyses, using conventional cumulative techniques, to measure how many false positives would have occurred if these meta-analyses had been updated after each new trial. For each false positive, we performed TSA, using three different approaches. RESULTS We screened 4736 systematic reviews to find 100 meta-analyses that fulfilled our inclusion criteria. Using conventional cumulative meta-analysis, false positives were present in seven of the meta-analyses (7%, 95% CI 3% to 14%), occurring more than once in three. The total number of false positives was 14 and TSA prevented 13 of these (93%, 95% CI 68% to 98%). In a post hoc analysis, we found that Cochrane meta-analyses that are negative are 1.67 times more likely to be updated (95% CI 0.92 to 2.68) than those that are positive. CONCLUSIONS We found false positives in 7% (95% CI 3% to 14%) of the included meta-analyses. Owing to limitations of external validity and to the decreased likelihood of updating positive meta-analyses, the true proportion of false positives in meta-analysis is probably higher. TSA prevented 93% of the false positives (95% CI 68% to 98%).
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Affiliation(s)
- Georgina Imberger
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anaesthesia & Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kristian Thorlund
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen, Denmark
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8
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See Hoe LE, Schilling JM, Busija AR, Haushalter KJ, Ozberk V, Keshwani MM, Roth DM, Toit ED, Headrick JP, Patel HH, Peart JN. Chronic β1-adrenoceptor blockade impairs ischaemic tolerance and preconditioning in murine myocardium. Eur J Pharmacol 2016; 789:1-7. [PMID: 27373851 DOI: 10.1016/j.ejphar.2016.06.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 01/20/2023]
Abstract
β-adrenoceptor antagonists are commonly used in ischaemic heart disease (IHD) patients, yet may impair signalling and efficacy of 'cardioprotective' interventions. We assessed effects of chronic β1-adrenoceptor antagonism on myocardial resistance to ischaemia-reperfusion (IR) injury and the ability of cardioprotective interventions [classic ischaemic preconditioning (IPC); novel sustained ligand-activated preconditioning (SLP)] to reduce IR injury in murine hearts. Young male C57Bl/6 mice were untreated or received atenolol (0.5g/l in drinking water) for 4 weeks. Subsequently, two cardioprotective stimuli were evaluated: morphine pellets implanted (to induce SLP, controls received placebo) 5 days prior to Langendorff heart perfusion, and IPC in perfused hearts (3×1.5min ischaemia/2min reperfusion). Atenolol significantly reduced in vivo heart rate. Untreated control hearts exhibited substantial left ventricular dysfunction (~50% pressure development recovery, ~20mmHg diastolic pressure rise) with significant release of lactate dehydrogenase (LDH, tissue injury indicator) after 25min ischaemia/45min reperfusion. Contractile dysfunction and elevated LDH were reduced >50% with IPC and SLP. While atenolol treatment did not modify baseline contractile function, post-ischaemic function was significantly depressed compared to untreated hearts. Atenolol pre-treatment abolished beneficial effects of IPC, whereas SLP protection was preserved. These data indicate that chronic β1-adrenoceptor blockade can exert negative effects on functional IR tolerance and negate conventional IPC (implicating β1-adrenoceptors in IR injury and IPC signalling). However, novel morphine-induced SLP is resistant to inhibition by β1-adrenoceptor antagonism.
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Affiliation(s)
- Louise E See Hoe
- Menzies Health Institute Queensland, Griffith University, Southport, Australia
| | - Jan M Schilling
- VA San Diego Healthcare System, San Diego, USA; Department of Anesthesiology, University of California San Diego, USA
| | - Anna R Busija
- VA San Diego Healthcare System, San Diego, USA; Department of Anesthesiology, University of California San Diego, USA
| | - Kristofer J Haushalter
- VA San Diego Healthcare System, San Diego, USA; Department of Anesthesiology, University of California San Diego, USA; Department of Chemistry and Biochemistry, University of California San Diego, USA
| | - Victoria Ozberk
- Menzies Health Institute Queensland, Griffith University, Southport, Australia
| | - Malik M Keshwani
- Department of Pharmacology, University of California San Diego, USA
| | - David M Roth
- VA San Diego Healthcare System, San Diego, USA; Department of Anesthesiology, University of California San Diego, USA
| | - Eugene Du Toit
- Menzies Health Institute Queensland, Griffith University, Southport, Australia
| | - John P Headrick
- Menzies Health Institute Queensland, Griffith University, Southport, Australia
| | - Hemal H Patel
- VA San Diego Healthcare System, San Diego, USA; Department of Anesthesiology, University of California San Diego, USA
| | - Jason N Peart
- Menzies Health Institute Queensland, Griffith University, Southport, Australia.
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9
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Ye X, Peng L, Kan H, Wang W, Geng F, Mu Z, Zhou J, Yang D. Acute Effects of Particulate Air Pollution on the Incidence of Coronary Heart Disease in Shanghai, China. PLoS One 2016; 11:e0151119. [PMID: 26942767 PMCID: PMC4778855 DOI: 10.1371/journal.pone.0151119] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/22/2016] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Evidence based on ecological studies in China suggests that short-term exposure to particulate matter (PM) is associated with cardiovascular mortality. However, there is less evidence of PM-related morbidity for coronary heart disease (CHD) in China. This study aims to investigate the relationship between acute PM exposure and CHD incidence in people aged above 40 in Shanghai. METHODS Daily CHD events during 2005-2012 were identified from outpatient and emergency department visits. Daily average concentrations for particulate matter with aerodynamic diameter less than 10 microns (PM10) were collected over the 8-year period. Particulate matter with aerodynamic diameter less than 2.5 microns (PM2.5) were measured from 2009 to 2012. Analyses were performed using quasi-poisson regression models adjusting for confounders, including long-term trend, seasonality, day of the week, public holiday and meteorological factors. The effects were also examined by gender and age group (41-65 years, and >65 years). RESULTS There were 619928 CHD outpatient and emergency department visits. The average concentrations of PM10 and PM2.5 were 81.7 μg/m3 and 38.6 μg/m3, respectively. Elevated exposure to PM10 and PM2.5 was related with increased risk of CHD outpatients and emergency department visits in a short time course. A 10 μg/m3 increase in the 2-day PM10 and PM2.5 was associated with increase of 0.23% (95% CI: 0.12%, 0.34%) and 0.74% (95% CI: 0.44%, 1.04%) in CHD morbidity, respectively. The associations appeared to be more evident in the male and the elderly. CONCLUSION Short-term exposure to high levels of PM10 and PM2.5 was associated with increased risk of CHD outpatient and emergency department visits. Season, gender and age were effect modifiers of their association.
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Affiliation(s)
- Xiaofang Ye
- Department of Environment Health, School of Public Health, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Meteorology and Health, Shanghai Meteorological Service, Shanghai, China
| | - Li Peng
- Shanghai Key Laboratory of Meteorology and Health, Shanghai Meteorological Service, Shanghai, China
| | - Haidong Kan
- School of Public Health and Key Laboratory of Public Health Safety (Ministry of Education), Fudan University, Shanghai, China
| | - Weibing Wang
- School of Public Health and Key Laboratory of Public Health Safety (Ministry of Education), Fudan University, Shanghai, China
- Fudan Tyndall Centre, Shanghai, China
| | - Fuhai Geng
- Shanghai Key Laboratory of Meteorology and Health, Shanghai Meteorological Service, Shanghai, China
| | - Zhe Mu
- Shanghai Key Laboratory of Meteorology and Health, Shanghai Meteorological Service, Shanghai, China
| | - Ji Zhou
- Shanghai Key Laboratory of Meteorology and Health, Shanghai Meteorological Service, Shanghai, China
| | - Dandan Yang
- Shanghai Key Laboratory of Meteorology and Health, Shanghai Meteorological Service, Shanghai, China
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Strandmark R, Herlitz J, Axelsson C, Claesson A, Bremer A, Karlsson T, Jimenez-Herrera M, Ravn-Fischer A. Determinants of pre-hospital pharmacological intervention and its association with outcome in acute myocardial infarction. Scand J Trauma Resusc Emerg Med 2015; 23:105. [PMID: 26626732 PMCID: PMC4665872 DOI: 10.1186/s13049-015-0188-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 11/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was a) To identify predictors of the use of aspirin in the pre-hospital setting in acute myocardial infarction (AMI) and b) To analyze whether the use of any of the recommended medications was associated with outcome. METHODS All patients with a final diagnosis of AMI, transported by the Emergency Medical Services (EMS) and admitted to the coronary care unit at Sahlgrenska University Hospital in Gothenburg, Sweden, in 2009-2011, were included. RESULTS 1,726 patients were included. 58 % received aspirin by the EMS. Ischemic heart disease (IHD) was suspected in 84 %. Among patients who did not receive aspirin IHD was still suspected in 67 %. Among patients in whom IHD was suspected, and who were not on chronic treatment with aspirin the following predicted its pre-hospital use: a) age (odds ratio 0.98; 95 % confidence interval (CI) 0.96-0.99); b) a history of myocardial infarction (2.21; 1.21-4.04); c) priority given by EMS (8.07; 5.42-12.02); d) ST-elevation on ECG on admission to hospital (2.22; 1.50-3.29); e) oxygen saturation > 90 % (3.37; 1.81-6.27). After adjusting for confounders among patients who were not on chronic aspirin, only nitroglycerin of the recommended medications was associated with a reduced risk of death within 1 year (hazard ratio 0.40; 95 % CI 0.23-0.70). CONCLUSIONS Less than six out of ten patients with AMI received pre-hospital aspirin. Five clinical factors were independently associated with the pre-hospital administration of aspirin. This suggests that the decision to treat is multifactorial, and it highlights the lack of accurate diagnostic tools in the pre-hospital environment. Nitroglycerin was independently associated with a reduced risk of death, suggesting that we select the use for a low-risk cohort.
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Affiliation(s)
- Rasmus Strandmark
- Department of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, Johan Herlitz office, Registercentrum i Västra Götaland, 413 45, Gothenburg, Sweden.
| | - Johan Herlitz
- Department of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Christer Axelsson
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Andreas Claesson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden.
| | - Anders Bremer
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Thomas Karlsson
- Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
| | | | - Annica Ravn-Fischer
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Effects of early blood pressure lowering on early and long-term outcomes after acute stroke: an updated meta-analysis. PLoS One 2014; 9:e97917. [PMID: 24853087 PMCID: PMC4031127 DOI: 10.1371/journal.pone.0097917] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 04/26/2014] [Indexed: 11/26/2022] Open
Abstract
Background Hypertension is common after acute stroke onset. Previous studies showed controversial effects of early blood pressure (BP) lowering on stroke outcomes. The aim of this study is to assess the effects of early BP lowering on early and long-term outcomes after acute stroke. Methods A meta-analysis was conducted with prospective randomized controlled trials assessing the effects of early BP lowering on early and long-term outcomes after acute stroke compared with placebo. Literature searching was performed in the databases from inception to December 2013. New evidence from recent trials were included. Outcomes were analyzed as early (within 30 days) and long-term (from 3 to 12 months) endpoints using summary estimates of relative risks (RR) and their 95% confidence intervals (CI) with the fixed-effect model or random-effect model. Results Seventeen trials providing data from 13236 patients were included. Pooled results showed that early BP lowering after acute stroke onset was associated with more death within 30 days compared with placebo (RR: 1.34 and 95% CI: 1.02, 1.74, p = 0.03). However the results showed that early BP lowering had no evident effect on early neurological deterioration, early death within 7 days, long-term death, early and long-term dependency, early and long-term combination of death or dependency, long-term stroke recurrence, long-term myocardial infarction and long-term CVE. Conclusions The new results lend no support to early BP lowering after acute stroke. Early BP lowering may increase death within 30 days after acute stroke.
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Vadera R. Does Antihypertensive Drug Therapy Decrease Morbidity or Mortality in Patients With a Hypertensive Emergency? Ann Emerg Med 2011; 57:64-5. [DOI: 10.1016/j.annemergmed.2010.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 05/12/2010] [Accepted: 05/17/2010] [Indexed: 11/26/2022]
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Sinert R, Newman DH, Brandler E, Paladino L. Immediate β-Blockade in Patients With Myocardial Infarctions: Is There Evidence of Benefit? Ann Emerg Med 2010; 56:571-7. [DOI: 10.1016/j.annemergmed.2010.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Revised: 03/25/2010] [Accepted: 03/25/2010] [Indexed: 10/19/2022]
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