Meta-Analysis for Impact of Statin on Mortality After Transcatheter Aortic Valve Implantation

Statin treatment after surgical aortic valve replacement for aortic stenosis is associated with better long-term outcome

OBJECTIVES

The aim of this study was to evaluate the association between statin use after surgical aortic valve replacement for aortic stenosis and long-term risk for major adverse cardiovascular events (MACEs) in a large population-based, nationwide cohort.

METHODS

All patients who underwent isolated surgical aortic valve replacement due to aortic stenosis in Sweden 2006-2020 and survived 6 months after discharge were included. Individual patient data from 5 nationwide registries were merged. Primary outcome is MACE (defined as all-cause mortality, myocardial infarction or stroke). Multivariable Cox regression model adjusted for age, sex, comorbidities, valve type, operation year and secondary prevention medications is used to evaluate the association between time-updated dispense of statins and long-term outcome in the entire study population and in subgroups based on age, sex and comorbidities.

RESULTS

A total of 11 894 patients were included. Statins were dispensed to 49.8% (5918/11894) of patients at baseline, and 51.0% (874/1713) after 10 years. At baseline, 3.6% of patients were dispensed low dose, 69.4% medium dose and 27.0% high-dose statins. After adjustments, ongoing statin treatment was associated with a reduced risk for MACE [adjusted hazard ratio 0.77 (95% confidence interval 0.71-0.83). P < 0.001], mainly driven by a reduction in all-cause mortality [adjusted hazard ratio, 0.70 (0.64-0.76)], P < 0.001. The results were consistent in all subgroups.

CONCLUSIONS

The results suggest that statin therapy might be beneficial for patients undergoing surgical aortic valve replacement for aortic stenosis. Randomized controlled trials are warranted to establish causality between statin treatment and improved outcome.

A simply calculated nutritional index provides clinical implications in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Malnutrition is associated with adverse outcomes in patients with aortic stenosis. The Triglycerides × Total Cholesterol × Body Weight Index (TCBI) is a simple scoring model to evaluate the status of nutrition. However, the prognostic relevance of this index in patients undergoing transcatheter aortic valve replacement (TAVR) is unknown. This study aimed to evaluate the association of the TCBI with clinical outcomes in patients undergoing TAVR.

METHODS

A total of 1377 patients undergoing TAVR were evaluated in this study. The TCBI was calculated by the formula; triglyceride (mg/dL) × total cholesterol (mg/dL) × body weight (kg)/1000. The primary outcome was all-cause mortality within 3 years.

RESULTS

Patients with a low TCBI, based on a cut-off value of 985.3, were more likely to have elevated right atrial pressure (p = 0.04), elevated right ventricular pressure (p < 0.01), right ventricular systolic dysfunction (p < 0.01), tricuspid regurgitation ≥ moderate (p < 0.01). Patients with a low TCBI had a higher cumulative 3-year all-cause (42.3% vs. 31.6%, p < 0.01; adjusted HR 1.36, 95% CI 1.05-1.77, p = 0.02) and non-cardiovascular mortality (15.5% vs. 9.1%, p < 0.01; adjusted HR 1.95, 95% CI 1.22-3.13, p < 0.01) compared to those with a high TCBI. Adding a low TCBI to EuroSCORE II improved the predictive value for 3-year all-cause mortality (net reclassification improvement, 0.179, p < 0.01; integrated discrimination improvement, 0.005, p = 0.01).

CONCLUSION

Patients with a low TCBI were more likely to have right-sided heart overload and exhibited an increased risk of 3-year mortality. The TCBI may provide additional information for risk stratification in patients undergoing TAVR.

Association between perioperative statin treatment and short-term clinical outcomes following transcatheter aortic valve implantation: a retrospective cohort study

BACKGROUND

Studies have found statin treatment to be associated with improved 1-year survival after transcatheter aortic valve implantation (TAVI), suggesting pleiotropic effects of statins on preventing perioperative complications. Statin treatment is not associated with postoperative cardiovascular complications or mortality; however, other postoperative complications have not been investigated.

AIM

To explore whether preoperative statin treatment is associated with a lower short-term risk of mortality, readmission and major postoperative complications in older patients undergoing TAVI.

METHODS

A retrospective cohort study including patients aged 65 years and older who had undergone a comprehensive geriatric assessment prior to TAVI between January 2014 and January 2021. The primary outcomes were 90-day mortality, 90-day readmissions and major postoperative complications according to the Clavien-Dindo classification. Multivariable logistic regression was performed with adjustment for potential confounders, namely age, gender, comorbidity, body mass index, smoking, diminished renal function, alcohol use and falls .

RESULTS

This study included 584 patients, of whom 324 (55.5%) were treated with a statin. In the statin treated group, 15 (4.6%) patients died within 90 days of TAVI compared with 10 (3.8%) patients in the non statin group (adjusted OR 1.17; 95% CI 0.51 to 2.70). The number of 90-day readmissions was 39 (12.0%) and 34 (13.1%) (adjusted OR 0.91; 95% CI 0.54 to 1.52), respectively. In the statin treated group, 115 (35.5%) patients experienced a major complication compared with 98 (37.7%) in the non-statin group (adjusted OR 0.95; 95% CI 0.67 to 1.37).

CONCLUSION

Preoperative statin treatment is not associated with improved short-term outcomes after TAVI. A randomised controlled trial with different statin doses may be warranted to investigate whether initiating statin treatment before TAVI improves both postoperative outcomes and long-term survival.

P2Y12 Inhibitors for Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis

BACKGROUND

For patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), prasugrel was recommended over ticagrelor in a recent randomized controlled trial, although more data are needed on the rationale. Here, the effects of P2Y12 inhibitors on ischemic and bleeding events in patients with NSTE-ACS were investigated.

METHODS

Clinical trials that enrolled patients with NSTE-ACS were included, relevant data were extracted, and a network meta-analysis was performed.

RESULTS

This study included 37,268 patients with NSTE-ACS from 11 studies. There was no significant difference between prasugrel and ticagrelor for any end point, although prasugrel had a higher likelihood of event reduction than ticagrelor for all end points except cardiovascular death. Compared with clopidogrel, prasugrel was associated with decreased risks of major adverse cardiovascular events (MACE) (hazard ratio [HR], 0.84; 95% CI, 0.71-0.99) and myocardial infarction (HR, 0.82; 95% CI, 0.68-0.99) but not an increased risk of major bleeding (HR, 1.30; 95% CI, 0.97-1.74). Similarly, compared with clopidogrel, ticagrelor was associated with a reduced risk of cardiovascular death (HR, 0.79; 95% CI, 0.66-0.94) and an increased risk of major bleeding (HR, 1.33; 95% CI, 1.00-1.77; P = .049). For the primary efficacy end point (MACE), prasugrel showed the highest likelihood of event reduction (P = .97) and was superior to ticagrelor (P = .29) and clopidogrel (P = .24).

CONCLUSION

Prasugrel and ticagrelor had comparable risks for every end point, although prasugrel had the highest probability of being the best treatment for reducing the primary efficacy end point. This study highlights the need for further studies to investigate optimal P2Y12 inhibitor selection in patients with NSTE-ACS.

Impact of PPAR-gamma activation on the durability of biological heart valve prostheses in hypercholesterolaemic rats

OBJECTIVES

Hypercholesterolaemia and obesity are risk factors for the development of calcified aortic valve disease and common comorbidities in respective patients. Peroxisome proliferator-activated receptor gamma activation has been shown to reduce the progression of native aortic valve sclerosis, while its effect on bioprosthetic valve degeneration is yet unknown. This project aims to analyse the impact of pioglitazone, a peroxisome proliferator-activated receptor gamma agonist, on the degeneration of biological aortic valve conduits in an implantation model in obese and hypercholesterolaemic rats.

METHODS

Cryopreserved allogenic rat aortic valve conduits (n = 40) were infrarenally implanted into Wistar rats on high-fat (34.6%) diet. One cohort was treated with pioglitazone (75 mg/kg chow; n = 20, group PIO) and compared to untreated rats (n = 20, group control). After 4 or 12 weeks, conduits were explanted and analysed by (immuno-)histology and real-time polymerase chain reaction.

RESULTS

A significantly decreased intima hyperplasia occurred in group PIO compared to control after 4 (P = 0.014) and 12 weeks (P = 0.045). Calcification of the intima was significantly decreased in PIO versus control at 12 weeks (P = 0.0001). No significant inter-group differences were shown for media calcification after 4 and 12 weeks. Echocardiographically, significantly lower regurgitation through the implanted aortic valve conduit was observed in PIO compared to control after 4 (P = 0.018) and 12 weeks (P = 0.0004). Inflammatory activity was comparable between both groups.

CONCLUSIONS

Systemic peroxisome proliferator-activated receptor gamma activation decreases intima hyperplasia and subsequent intima calcification of cryopreserved allografts in obese, hypercholesterolaemic recipients. Additionally, it seems to inhibit functional impairment of the implanted aortic valve. Further preclinical studies are required to determine the long-term impact of peroxisome proliferator-activated receptor gamma agonists on graft durability.

Effects of renin-angiotensin system inhibitor type and dosage on survival after transcatheter aortic valve implantation

AIMS

The objective of the study was to determine the effect of renin-angiotensin system inhibitors (RASI) on the survival of subgroups of patients with aortic stenosis after transcatheter aortic valve implantation (TAVI) and to assess the impact of types and dosages of RASI on outcomes.

METHODS AND RESULTS

This single-centre, retrospective analysis included 2862 patients (n = 2227 with RASI and n = 635 without RASI) after successful TAVI. Propensity score matching established comparable patient populations (n = 625 per group). Survival was analysed by Kaplan-Meier curves and Cox regression and was corrected for baseline, procedural, and medical parameters. Self-reported adherence to RASI therapy 3 months after hospital discharge was 94%. Three-year all-cause mortality rates were 12.3% and 20.2% for patients with or without RASI, respectively (log-rank <0.001). In the matched study populations, mortality rates were 14.2% vs. 20.0% (log-rank <0.03). RASI was particularly beneficial in patients with ejection fraction <40% [adjusted hazard ratio (HR) and 95% confidence interval 0.50 (0.29-0.87)], EuroScore II ≥4% [HR 0.47 (0.35-0.65)], or low-flow, low-gradient aortic stenosis [HR 0.53 (0.31-0.93)] who were also on beta-blockers and statins. An association between discharge dosage and survival was observed, with HR 0.75 (0.58-0.96) and 0.57 (0.44-0.72) for patients on <50% and ≥50% target dose, respectively. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) reduced mortality rates similarly (13.9% vs. 9.8%, log-rank 0.103).

CONCLUSIONS

The beneficial association between RASI after TAVI and improved survival during follow-up is particularly evident in high-risk patients and may be dose dependent. No superiority was noted in the effectiveness of ACEI or ARB.

Statins and Mortality of Patients After Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-analysis

While TAVI is widely used, optimal medical therapy to reduce the mortality rate after transcatheter aortic valve implantation (TAVI) is still unclear. We performed a systematic review and meta-analysis to evaluate the impact of statins on mortality following TAVI. Present systematic review of the literature was performed using Medline, Embase, Scopus, and Web of Science; all studies reported all-cause mortality in patients who underwent TAVI and received or did not receive statin therapy. Data were analyzed using random-effects models. Seventeen articles (21 380 patients) were included in the meta-analysis. Statin therapy was associated with a reduction of all-cause mortality (Hazard ratio [HR] = .78, 95% Confidence interval [CI] .68-.89, P < .001). Moderate between-study heterogeneity was observed (I² = 45.2). High-intensity statin therapy was more effective than low or moderate intensity statin therapy in reduction of all-cause mortality (Risk ratio [RR] = .62, 95% CI 0.45-.85, P = .003, I² = .0). Statin therapy could reduce the mid-term all-cause mortality rate following TAVI. However, all included studies were observational and, therefore, randomized controlled trials are still needed to assess the effect of statin therapy on mortality after TAVI.

Associations between medical therapy after surgical aortic valve replacement for aortic stenosis and long-term mortality: a report from the SWEDEHEART registry

AIMS

The association between the use of statins, renin-angiotensin system (RAS) inhibitors, and/or β-blockers and long-term mortality in patients with aortic stenosis (AS) who underwent surgical aortic valve replacement (SAVR) is unknown.

METHODS AND RESULTS

All patients with AS who underwent isolated first-time SAVR in Sweden from 2006 to 2017 and survived 6 months after discharge were included. Individual patient data from four mandatory nationwide registries were merged. Cox proportional hazards models, with time-updated data on medication status and adjusted for age, sex, comorbidities, type of prosthesis, and year of surgery, were used to investigate associations between dispensed statins, RAS inhibitors, and β-blockers and all-cause mortality. In total, 9553 patients were included, and the median follow-up time was 4.9 years (range 0-11); 1738 patients (18.2%) died during follow-up. Statins were dispensed to 49.1% and 49.0% of the patients within 6 months of discharge from the hospital and after 10 years, respectively. Corresponding figures were 51.4% and 53.9% for RAS inhibitors and 79.3% and 60.7% for β-blockers. Ongoing treatment was associated with lower mortality risk for statins {adjusted hazard ratio (aHR) 0.67 [95% confidence interval (95% CI) 0.60-0.74]; P < 0.001} and RAS inhibitors [aHR 0.84 (0.76-0.93); P < 0.001] but not for β-blockers [aHR 1.17 (1.05-1.30); P = 0.004]. The associations were robust in subgroups based on age, sex, and comorbidities (P for interactions >0.05).

CONCLUSIONS

The results of this large population-based real-world study support the use of statins and RAS inhibitors for patients who underwent SAVR due to AS.

Effect of lipid-lowering medications in patients with coronary artery bypass grafting surgery outcomes

BACKGROUND

Increased life expectancy and improved medical technology allow increasing numbers of elderly patients to undergo cardiac surgery. Elderly patients may be at greater risk of postoperative morbidity and mortality. Complications can lead to worsened quality of life, shortened life expectancy and higher healthcare costs. Reducing perioperative complications, especially severe adverse events, is key to improving outcomes in patients undergoing cardiac surgery. The objective of this study is to determine whether perioperative lipid-lowering medication use is associated with a reduced risk of complications and mortality after coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB).

METHODS

After IRB approval, we reviewed charts of 9,518 patients who underwent cardiac surgery with CPB at three medical centers between July 2001 and June 2015. The relationship between perioperative lipid-lowering treatment and postoperative outcome was investigated. 3,988 patients who underwent CABG met inclusion criteria and were analyzed. Patients were divided into lipid-lowering or non-lipid-lowering treatment groups.

RESULTS

A total of 3,988 patients were included in the final analysis. Compared to the patients without lipid-lowering medications, the patients with lipid-lowering medications had lower postoperative neurologic complications and overall mortality (P < 0.05). Propensity weighted risk-adjustment showed that lipid-lowering medication reduced in-hospital total complications (odds ratio (OR) = 0.856; 95% CI 0.781-0.938; P < 0.001); all neurologic complications (OR = 0.572; 95% CI 0.441-0.739; P < 0.001) including stroke (OR = 0.481; 95% CI 0.349-0.654; P < 0.001); in-hospital mortality (OR = 0.616; 95% CI 0.432-0.869; P = 0.006; P < 0.001); and overall mortality (OR = 0.723; 95% CI 0.634-0.824; P < 0.001). In addition, the results indicated postoperative lipid-lowering medication use was associated with improved long-term survival in this patient population.

CONCLUSIONS

Perioperative lipid-lowering medication use was associated with significantly reduced postoperative adverse events and improved overall outcome in elderly patients undergoing CABG surgery with CPB.

The risk of stent thrombosis of dual antithrombotic therapy for patients who require oral anticoagulant undergoing percutaneous coronary intervention: insights of a meta-analysis of randomized trials

Recent meta-analyses investigating dual antithrombotic therapy (DAT) versus triple antithrombotic therapy (TAT) among patients who require oral anticoagulants especially with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) raised the concern of stent thrombosis (ST) and myocardial infarction (MI), however, these meta-analyses did not include all randomized trials who require oral anticoagulants. We aimed to investigate the efficacy of DAT versus TAT in these patients undergoing PCI. Our data showed the risk of ST was not significantly different in DAT vs. TAT (HR [95%CI]: 1.50 [0.97-2.34], p = .07; I² = 0%) and MI (HR [95%CI]: 1.17 [0.95-1.45], p = .14; I² = 0%).

Influence of polyvascular disease on clinical outcome in patients undergoing transcatheter aortic valve implantation via transfemoral access

Background

The influence of polyvascular disease (PVD) on the short- and long-term clinical outcomes of patients undergoing transcatheter aortic valve implantation via trans-femoral access (TF-TAVI) has not been fully elucidated.

Methods

A total of 2167 patients from the Optimized CathEter vAlvular iNtervention-TAVI (OCEAN-TAVI) registry who underwent TF-TAVI was studied. PVD was defined as the presence of at least two of the following vascular bed (VB) diseases: concomitant coronary artery disease (CAD), cerebrovascular disease (CVD), and peripheral artery disease (PAD).

Results

Patients with PVD (288 patients, 13.3%) had a higher incidence of in-hospital complications, such as AKI (16.3% vs. 7.0%, p<0.01) and disabling stroke (3.5% vs. 1.2%, p<0.01) than patients without PVD. These complications caused higher rates of procedural mortality (4.5% vs. 2.0%, p<0.01). PVD increased the risk of the 2-year rate of cardiovascular death (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.04–2.50; p<0.05); however, non-cardiovascular death, myocardial infarction, or ischemic stroke was not associated with PVD. Worsening heart failure (4.6% vs. 1.1%, p<0.01) was the main cause of cardiovascular death among patients with PVD. In a sub-analysis, compared with patients with AS alone, those with 2 VB diseases (CAD+PAD; adjusted HR, 1.93; 95% CI, 1.06–3.53; p<0.05) and 3 VB diseases (CAD+CVD+PAD; adjusted HR, 2.61; 95% CI, 1.21–5.62; p<0.05) had a higher risk of 2-year cardiovascular death.

Conclusions

The increased prevalence of concomitant atherosclerotic VB diseases before TF-TAVI may increase the rates of in-hospital complications and 2-year cardiovascular death. Given the higher rate of mortality in patients with PVD undergoing TF-TAVI, future studies focusing on medical therapy are needed to reduce long-term cardiovascular events in this high-risk subset.

Effects of statins after transcatheter aortic valve implantation in key patient populations

ABSTRACT

Statin therapy after transcatheter aortic valve replacement (TAVI) is associated with better short- and long-term outcomes. It is of interest to identify specific patient populations that might profit from statin therapy. In this retrospective, observational analysis of 2,862 patients with symptomatic aortic stenosis (AS) after successful transfemoral TAVI, survival during a three-year observation period was characterized by Kaplan-Meier analyses according to statin therapy. Hazard ratios and potential interactions for specific subgroups of patients were determined by Cox regression analyses. At hospital discharge 1,761 patients were on low- or moderate-intensity statins (LMIS), 246 patients were on high-intensity statins (HIS), and 855 patients did not take statins. Statin therapy adherence during the first three months post-TAVI was 91%. Mortality rates were 18.5%, 12.9%, and 6.9% for patients with no statin, LMIS, and HIS (p<0.001). Any statin therapy proved to be effective in patients in different classes of age, risk, and manifest cardiovascular disease and was independent of background medication. Statins were of particular benefit in high-risk patients with coronary artery disease (hazard ratio (HR)=0.57), ejection fraction < 40% (HR=0.64), or low-flow low-gradient AS (HR=0.58) and showed additional benefit even in patients taking renin-angiotensin system blockers (HR=0.74). Statins also reduced mortality in patients with malignant disease (HR=0.47). Our analysis confirmed the beneficial effect of statins on survival after TAVI and documented this phenomenon in key patient subsets. The protective effect of statins in our study is consistent with the cardioprotective mechanisms but must be explained by other, yet undetermined pleiotropic effects of statins.

Potent P2Y12 inhibitors versus Clopidogrel in elderly patients with acute coronary syndrome: Systematic review and meta-analysis

BACKGROUND

Potent P2Y12 inhibitors reduce cardiovascular events but increase bleeding in patients presenting with acute coronary syndrome (ACS). Elderly patients are at increased risk of bleeding and whether the benefit-risk ratio of potent P2Y12 inhibitors remains favorable is not known.

OBJECTIVES

To investigate the efficacy and safety of potent P2Y12 inhibitors versus clopidogrel in elderly patients with ACS.

METHODS

PUBMED and EMBASE were searched through July 2020 for randomized control trials (RCTs) or subgroup analyses of RCTs investigating potent P2Y12 inhibitors (prasugrel or ticagrelor) or clopidogrel in elderly (age ≥ 65 years) patients with ACS. The primary outcome was major adverse cardiovascular events (MACE).

RESULTS

Our search identified 9 RCTs with a total of 10,792 elderly patients. When compared with clopidogrel, potent P2Y12 inhibitors had similar risk of MACE (hazard ratio (HR): 0.94; 95%; confidence interval (CI) [0.85-1.06], P = .31, I² = 9%), all-cause mortality (HR: 0.89; 95% CI [0.74-1.07], P = .22, I² = 29%), reduced the risk of cardiovascular death (HR: 0.82; 95% CI [0.68-0.98], P = .03, I² = 16%) but increased the risk of major bleeding (HR: 1.27; 95% CI [1.04-1.56], P = .02, I² = 0%). In a subgroup analysis, ticagrelor reduced all-cause mortality (HR: 0.73; 95% CI [0.55-0.98]) and cardiovascular death (HR: 0.70; 95% CI [0.54-0.90]) compared with clopidogrel.

CONCLUSIONS

Among elderly patients with ACS, potent P2Y12 inhibitors reduce cardiovascular death but increase bleeding with no difference in MACE or all-cause death when compared with clopidogrel. Further RCTs are needed to refine P2Y12 inhibitor selection for elderly patients with ACS.

Statin therapy for patients with aortic stenosis who underwent transcatheter aortic valve implantation: a report from a Japanese multicentre registry

OBJECTIVE

Data on statin for patients with aortic stenosis (AS) who underwent transcatheter aortic valve implantation (TAVI) are limited. The present study aimed to evaluate the impact of statin on midterm mortality of TAVI patients.

DESIGN

Observational study.

SETTING

This study included patients with AS from a Japanese multicentre registry who underwent TAVI.

PARTICIPANTS

The overall cohort included 2588 patients (84.4±5.2 years); majority were women (69.3%). The Society of Thoracic Surgeons risk score was 6.55% (IQR 4.55%-9.50%), the Euro II score was 3.74% (IQR 2.34%-6.02%) and the Clinical Frailty Scale score was 3.9±1.2.

INTERVENTIONS

We classified patients based on statin at admission and identified 936 matched pairs after propensity score matching.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcomes were all-cause and cardiovascular mortality.

RESULTS

The median follow-up was 660 days. Statin at admission was associated with a significant reduction in all-cause mortality (adjusted HR (aHR) 0.76, 95% CI 0.58 to 0.99, p=0.04) and cardiovascular mortality (aHR 0.64, 95% CI 0.42 to 0.97, p=0.04). In the octogenarians, statin was associated with significantly lower all-cause mortality (aHR 0.87, 95% CI 0.75 to 0.99, p=0.04); however, the impact in the nonagenarians appeared to be lower (aHR 0.84, 95% CI 0.62 to 1.13, p=0.25). Comparing four groups according to previous coronary artery disease (CAD) and statin, there was a significant difference in all-cause mortality, and patients who did not receive statin despite previous CAD showed the worst prognosis (aHR 1.33, 95% CI 1.12 to 1.57 (patients who received statin without previous CAD as a reference), p<0.01).

CONCLUSIONS

Statin for TAVI patients will be beneficial even in octogenarians, but the benefits may disappear in nonagenarians. In addition, statin will be essential for TAVI patients with CAD. Further research is warranted to confirm and generalise our findings since this study has the inherent limitations of an observational study and included only Japanese patients.

TRIAL REGISTRATION NUMBER

UMIN000020423.

Clinical outcomes of transcatheter aortic valve implantation in failed bioprosthetic surgical valves vs. native aortic stenosis: insights from a meta-analysis

There is no meta-analysis comparing clinical outcomes between valve-in-valve transcatheter aortic valve implantation for failed surgical bioprosthetic valves (ViV-TAVI) and native valve TAVI for aortic stenosis (NV-TAVI). We aimed to investigate clinical outcomes between ViV-TAVI and NV-TAVI using a meta-analysis. EMBASE and MEDLINE were searched through April 2020 to investigate the comparative outcomes between ViV-TAVI and NV-TAVI. The main outcomes were short-term (30-day/in-hospital) mortality, pacemaker implantation (PMI), life threatening and/or major bleeding, stroke, and coronary obstruction, and long-term (1-year) mortality and stroke. Our search identified 5 observational studies enrolling a total of 8428 patients (1442 patients with ViV-TAVI and 6986 with NV-TAVI). ViV-TAVI was associated with significantly lower rates of short-term mortality, PMI, and life threatening and/or major bleeding, compared with NV-TAVI (relative risk [RR] [95% CI] 0.54 [0.34-0.84], P = 0.007; 0.25 [0.19-0.35], P < 0.0001; 0.64 [0.46-0.89], P = 0.008, respectively). There were no significant differences in rates of short-term stroke and coronary obstruction between ViV-TAVI and NV-TAVI (RR [95% CI] 0.59 [0.35-1.01], P = 0.06; 1.86 [0.78-4.41], P = 0.16, respectively). ViV-TAVI was also associated with a significantly lower rate of 1-year mortality compared with NV-TAVI (RR [95% CI] 0.64 [0.51-0.81], P = 0.0002), whereas there was no significant difference in long-term stroke (RR [95% CI] 0.71 [0.45-1.12], P = 0.51). ViV-TAVI was associated with significantly lower rates of short-term mortality, PMI, and life threatening and/or major bleeding, and long-term mortality, without increased risks of stroke and coronary obstruction, compared with NV-TAVI.

Optimal Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome: Insights From a Network Meta-Analysis of Randomized Trials

BACKGROUND

With newer generation drug eluting stents (DES), the minimal duration of dual antiplatelet therapy (DAPT) recommended by guidelines has been reduced to 6 months in patients with stable coronary artery disease. Whether shorter duration of DAPT is safe in patients presenting with acute coronary syndrome (ACS) remains controversial. Our aim of this study was to investigate the optimal DAPT duration (≤3 months vs. 6 months vs. 12 months vs. >12 months) among patients with ACS undergoing percutaneous coronary intervention (PCI).

METHODS

PUBMED and EMBASE were searched through January 2020 for randomized controlled trials of DAPT duration in patients with ACS. The ischemic outcomes were all-cause death, myocardial infarction, and stent thrombosis. The safety outcome was major and/or clinically relevant bleeding.

RESULTS

Our search identified 14 eligible trials enrolling a total of 31,837 patients comparing different DAPT duration in patients with ACS. Short-term DAPT (≤3 months or 6 months) did not increase ischemic outcomes compared to long-term DAPT (12 months and >12 months). For bleeding outcomes, ≤3 months DAPT was associated with significant reduction in bleeding compared to 6 months, 12 months or >12 months DAPT (OR [95% CI]: 0.60 [0.37-0.98]; 0.68 [0.54-0.85] and 0.43 [0.34-0.54], respectively). These findings were similar when limited to 2nd generation DES.

CONCLUSIONS

Data from this meta-analysis of randomized trials support short-term (≤3 months and 6 months) DAPT in patients with ACS undergoing PCI. Guidelines might need to consider short-term DAPT even in patients presenting with ACS, especially in this era of newer generation DES.

P2Y12 inhibitor monotherapy versus aspirin monotherapy after short-term dual antiplatelet therapy for percutaneous coronary intervention: Insights from a network meta-analysis of randomized trials

BACKGROUND

A number of trials have assessed the efficacy and safety of short-term dual antiplatelet therapy (DAPT) in patients who undergo percutaneous coronary intervention (PCI). However, whether to continue aspirin or a P₂Y₁₂ inhibitor after a short course of DAPT is actively debated.

METHODS

PUBMED and EMBASE were searched through March 2020 for randomized controlled trials evaluating short-term DAPT (≤6 months) when compared with longer-term (≥12 months) DAPT among patients undergoing PCI. The ischemic outcomes were all-cause death, myocardial infarction, stent thrombosis, and stroke. The safety outcome was major and/or clinically relevant bleeding. The primary objective was to investigate the outcomes with aspirin monotherapy (Aspirin group) versus P₂Y₁₂ inhibitor monotherapy (P2Y12i group) after short-term DAPT.

RESULTS

Our search identified 17 eligible trials enrolling a total of 54,625 patients comparing different DAPT duration. Either of the 2 monotherapy groups did not increase the risk of ischemic outcomes when compared with the long-term DAPT group, without difference between the Aspirin versus the P2Y12i groups. However, both monotherapy groups significantly reduced bleeding when compared with long-term DAPT (Aspirin group: hazard ratio [95% CI]: 0.62 [0.45-0.86], P=.004 and P2Y12i group: 0.68 [0.50-0.93], P=.015). There was no difference in bleeding between the Aspirin versus P2Y12i groups (hazard ratio=0.91 [0.58-1.43], P=.70).

CONCLUSIONS

Among patients undergoing PCI, short-term DAPT with continuation of either aspirin or P2Y12i reduced bleeding without increasing ischemic outcomes when compared with long-term DAPT. The choice of antiplatelet therapy after short-term DAPT should be evaluated in well-powered trials.

Mortality in patients undergoing revascularization with paclitaxel eluting devices for infrainguinal peripheral artery disease: Insights from a network meta-analysis of randomized trials

OBJECTIVES

We aimed to evaluate whether paclitaxel eluting devices increased the risk of death in patients undergoing revascularization for infrainguinal peripheral artery disease using network meta-analyses.

METHODS

PUBMED and EMBASE were searched through April 2020 for randomized trials in patients with infrainguinal peripheral artery disease who underwent revascularization with or without a paclitaxel eluting device (balloon/stent). Short-term mortality defined as death at 6-12 months, and long-term mortality defined as death at >12 months after revascularization.

RESULTS

Our search identified 57 eligible randomized controlled studies enrolling a total of 9,362 patients comparing seven revascularization strategies (balloon angioplasty vs. bare metal stent vs. covered stent vs. paclitaxel eluting stent vs. other drug eluting stent vs. paclitaxel-coated balloon vs. bypass surgery). Overall, paclitaxel eluting stent and paclitaxel-coated balloons did not increase short-term mortality (eg, vs. balloon angioplasty: paclitaxel-coated balloon OR [95% CI] 1.21 [0.88-1.66], p = .24; paclitaxel eluting stent OR [95%CI] 1.01 [0.63-1.63], p = .97, respectively). In addition, paclitaxel eluting stent did not show significant increase in long-term mortality (eg, vs. balloon angioplasty: OR [95%CI] 1.06 [0.70-1.59], p = .79). However, paclitaxel-coated balloon showed significant increase in long-term mortality compared to balloon angioplasty and bypass (vs. balloon angioplasty: OR [95% CI] 1.48 [1.06-2.07], p = .021; vs. bypass: OR [95%CI] 1.73 [1.05-2.84], p = .031, respectively).

CONCLUSIONS

In this meta-analysis of randomized trials, there was no significant increase in mortality with paclitaxel eluting stent, but there was increased risk of long-term mortality in paclitaxel-coated balloon for the treatment of infrainguinal peripheral artery disease.

Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention; insights from a meta-analysis

BACKGROUND

The optimal antithrombotic regimen for patients undergoing percutaneous coronary intervention in acute coronary syndrome with concomitant atrial fibrillation is largely under investigation.

METHOD

PUBMED and EMBASE were searched through October 2019 for randomized trials or subgroup analyses of randomized trials investigating different antithrombotic strategies in patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention. We compared dual antithrombotic therapy versus triple antithrombotic therapy. Dual antithrombotic therapy was defined as vitamin K antagonist or direct oral anticoagulant plus P2Y12 inhibitor. Triple antithrombotic therapy was defined as vitamin K antagonist or direct oral anticoagulant plus dual antiplatelet therapy (aspirin plus P2Y12 inhibitor). The primary safety outcome was trial outcome was trial defined major adverse cardiovascular events.

RESULTS

Our search identified 5 eligible subgroup analyses of randomized controlled trials that enrolled a total of 4733 patients. Dual antithrombotic therapy significantly decreased the bleeding risk when compared with triple antithrombotic therapy (hazard ratio: 0.61; 95% confidential interval [0.51-0.71], P < 0.001, I = 31%). However, there were no significant differences in major adverse cardiovascular event between dual antithrombotic therapy versus triple antithrombotic therapy (hazard ratio: 1.08; 95% confidential interval: 0.89-1.31, P = 0.44, I = 0%).

CONCLUSION

In patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention, dual antithrombotic therapy was associated with lower bleeding risk compared with triple antithrombotic therapy while conferring similar major adverse cardiovascular event risk. Our results should be interpreted cautiously because we did not analyze the risk of stent thrombosis.

Meta-analysis of Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

For patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI), antithrombotic therapy including oral anticoagulants and antiplatelets are indicated. The optimal combination is not known. We investigated the efficacy and safety of different antithrombotic strategies in patients with AF undergoing PCI. PUBMED and EMBASE were searched through September 2019 for randomized trials investigating the efficacy and safety of different antithrombotic strategies in patients with AF who underwent PCI and/or acute coronary syndrome. Nine antithrombotic strategies were compared including combinations of vitamin K antagonist (VKA) with dual antiplatelet therapy (DAPT) or P2Y₁₂ inhibitor, combinations of direct oral anticoagulants (DOAC) (apixaban, dabigatran, rivaroxaban, and edoxaban) with DAPT or P2Y₁₂ inhibitor (clopidogrel, prasugrel, and ticagrelor). The primary safety outcome was trial defined primary bleeding outcome. The primary efficacy outcome was trial defined major adverse cardiovascular events. Our search identified 5 eligible trials that enrolled a total of 11,532 patients and compared 9 treatment strategies. VKA + DAPT significantly increased bleeding when compared with most combinations (for example, vs VKA + P2Y₁₂ inhibitor: odds ratio 2.11; 95% confidence interval [1.76 to 2.52], p <0.001). Of all the combinations, apixaban + P₂Y₁₂ inhibitor showed the lowest bleeding risk (for example, vs VKA + P2Y₁₂ inhibitor: odds ratio 0.63; 95% confidence interval [0.51 to 0.78], p <0.001) and was ranked the best treatment. There were no significant differences in ischemic outcome of major adverse cardiovascular events between various antithrombotic regimens. In conclusion, in patients with AF undergoing PCI, apixaban + P2Y₁₂ inhibitors were associated with lowest bleeding compared with other regimens including other DOACs + P2Y₁₂ inhibitors with no increase in ischemic outcomes.