Intracoronary abciximab reduces death and major adverse cardiovascular events in acute coronary syndromes: A meta-analysis of clinical trials

Clinical and angiographic characteristics of patients with spontaneous reperfusion in ST-segment elevation myocardial infarction

This study aims to investigate the clinical and angiographic characteristics of patients with spontaneous reperfusion in ST-segment elevation myocardial infarction (STEMI).A total of 519 patients with STEMI were enrolled in this study, who underwent primary percutaneous coronary intervention (PCI) treatments at Beijing Anzhen Hospital from January 2015 to December 2018. The patients were divided into 2 groups according to the TIMI flow grade before primary PCI, the non-spontaneous reperfusion group (TIMI flow grade 0-II) and the spontaneous reperfusion group (TIMI flow grade III). The incidence rate, the clinically relevant factors, and the features of the coronary angiographic lesions of spontaneous reperfusion from the 2 groups were recorded and analyzed.There were significant differences between the 2 groups in age, CTnI peak value, high thrombus burden, and locations of lesions in the distant of left anterior descending artery (LAD) (P = .000, .000, .002, .000, and .003, respectively). However, there were no significant differences between the groups in other clinic aspects including gender, hypertension, diabetes mellitus, smoking history, hyperlipemia, angina pectoris history, culprit vessel distribution, lesion distribution in left circumflex artery (LCX) and right coronary artery (RCA), and collateral circulation (P > .05 for all).Compared to the patients without spontaneous reperfusion, patients with spontaneous reperfusion were younger in age, lower in CTnI peak value, and higher in thrombosis burden, with culprit lesions mostly located in the distant of LAD.

Diagnostic Performance of the Instantaneous Wave-Free Ratio: Comparison With Fractional Flow Reserve

BACKGROUND

Aim of the present study was to perform a meta-analysis of all available studies comparing the instantaneous wave-free ratio (iFR) with fractional flow reserve (FFR).

METHODS AND RESULTS

Published trials comparing the iFR with FFR were searched for in PubMed, Google Scholar, and Scopus electronic databases. A total of 23 studies were available for the analysis, including 6381 stenoses. First, a meta-analysis of all studies was performed exploring the correlation between FFR and iFR. Interestingly, we found good correlation (0.798 [0.78-0.82]) between the 2 indices (P<0.001). In addition, to evaluate the diagnostic performance of iFR to identify FFR-positive coronary stenoses, we performed an additional meta-analysis, summarizing the results of receiver operating characteristics analyses from individual studies reporting the area under the curve. Summing the results of these studies, we found that iFR has a good diagnostic performance for the identification of FFR-positive stenoses (area under the curve=0.88 [0.86-0.90]; P<0.001). Furthermore, our search results included 5 studies that compared iFR and FFR to a third independent reference standard. Interestingly, no significant differences between iFR and FFR were reported in those studies.

CONCLUSIONS

The present meta-analysis shows that iFR significantly correlates with standard FFR and shows a good diagnostic performance in identifying FFR-positive coronary stenoses. Finally, iFR and FFR have similar diagnostic efficiency for detection of ischemia-inducing stenoses when tested against a third comparator.

Effect of intra-coronary administration of tirofiban through aspiration catheter on patients over 60 years with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

The aim of this study was to compare the efficacy and safety of 2 approaches for intra-coronary administration of tirofiban (aspiration catheter versus guiding catheter) in patients over 60 years of age undergoing percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). It has been suggested that the administration of tirofiban by intra-coronary injection could promote drug absorption in the diseased region and enhance the inhibition of platelet aggregation, decreasing bleeding rates, but little is known about the comparative efficiency and safety of using guiding catheter versus aspiration catheter for delivery.Eighty-nine patients over 60 years of age with STEMI undergoing PCI were randomly divided into 2 groups according to the injection route for intracoronary administration of tirofiban [guiding catheter (n = 41) and aspiration catheter (n = 48)]. Baseline features, epicardial and myocardial perfusion, major adverse cardiac and cerebrovascular events (MACCEs), and bleeding rate were compared.No differences in age, gender, and history of hypertension, hypercholesterolemia, diabetes, and so on were observed (P > .05). The patients in the aspiration catheter group generally had a higher incidence of cerebral vascular disease. Compared with those in the guiding catheter group, patients in the aspiration catheter group obtained more favorable myocardial perfusion (P < .05). In-hospital and at 3-month and 6-month follow-ups, the MACCE rate and frequency of bleeding events were similar between the 2 groups (P > .05).Intra-coronary delivery of tirofiban through aspiration catheter led to better myocardial perfusion in STEMI patients over 60 years of age undergoing PCI compared with intra-coronary injection of tirofiban through guiding catheter. The 2 delivery routes were associated with similar rates of MACCEs and bleeding events.

Should We Maintain Anticoagulation after Successful Radiofrequency Catheter Ablation of Atrial Fibrillation? The Need for a Randomized Study

Background

Atrial fibrillation (AF) is associated with a high risk of thromboembolic stroke and oral anticoagulation therapy (OAT) is able to reduce the rate of ischemic events. Nevertheless, the actual benefit of prolonged OAT after successful radiofrequency catheter ablation (RFCA) is not clear yet.

Methods

Scientific investigations were assumed suitable if they assessed the clinical significance of the use of anticoagulation versus no anticoagulation in AF patients undergoing successful RFCA. The odds ratio (OR) with 95% confidence interval (CI) was used as the study summary measure.

Results

At meta-analysis, the rate of total thromboembolic events was not significantly different between the groups (OR 1.83, 95% CI 0.69–4.88; p = 0.221), while a lower incidence of total bleeding events in patients not treated with OAT was found (OR 6.5, 95% CI 1.93–21.86; p = 0.002).

Conclusion

This meta-analysis raises doubts about the net clinical benefit (NCB) of a long-term prophylactic OAT in patients with AF underwent to successful RFCA. In fact, despite similar rate of thromboembolic events, the apparent increase in bleeding risk suggests caution in prolonging OAT after RFCA. However, the lack of prospective randomized studies does not allow a comprehensive appraisal of this issue. Thus, we propose the design of a novel prospective randomized trial to evaluate the NCB of prolonged OAT after successful RFCA of AF.

Long-term outcomes of coronary artery bypass grafting versus stent-PCI for unprotected left main disease: a meta-analysis

BACKGROUND

Coronary artery bypass graft (CABG) surgery has traditionally represented the standard of care for left main coronary artery (LMCA) disease. However, percutaneous coronary intervention with stent implantation (PCI) has more recently emerged as a valuable alternative. The long-time awaited results of the largest randomized trials on the long-term impact of PCI versus CABG in LMCA disease, the newly published NOBLE and EXCEL studies, revealed contrasting results. Thus, aim of the present meta-analysis was to review the most robust evidence from randomized comparisons of CABG versus PCI for revascularization of LMCA.

METHODS

Randomized studies comparing long-term clinical outcomes of CABG or Stent-PCI for the treatment of LMCA disease were searched for in PubMed, the Chochrane Library and Scopus electronic databases. A total of 5 randomized studies were selected, including 4499 patients.

RESULTS

No significant difference between CABG and PCI was found in the primary analysis on the composite endpoint of death, stroke and myocardial infarction (OR = 1·06 95% CI 0·80-1·40; p = 0·70). Similarly, no differences were observed between CABG and PCI for all-cause death (OR = 1·03 95% CI 0·81-1·32; p = 0·81). Although not statistically significant, a lower rate of stroke was registered in the PCI arm (OR = 0·86; p = 0·67), while a lower rate of myocardial infarction was found in the CABG arm (OR = 1·43; p = 0·17). On the contrary, a significantly higher rate of repeat revascularization was registered in the PCI arm (OR = 1·76 95% CI 1·45-2·13; p < 0·001).

CONCLUSIONS

The present meta-analysis, the most comprehensive and updated to date, including 5 randomized studies and 4499 patients, demonstrates no difference between Stent-PCI and CABG for the treatment of LMCA disease in the composite endpoint of death, stroke and myocardial infarction. Hence, a large part of patients with unprotected left main coronary artery disease can be managed equally well by means of both these revascularization strategies.

Clinic Predictive Factors for Insufficient Myocardial Reperfusion in ST-Segment Elevation Myocardial Infarction Patients Treated with Selective Aspiration Thrombectomy during Primary Percutaneous Coronary Intervention

Background. Insufficient data are available on the potential benefit of selective aspiration and clinical predictors for no-reflow in STEMI patients undergoing primary percutaneous coronary intervention (PPCI) adjunct with aspiration thrombectomy. Objective. The aim of our study was to investigate clinical predictors for insufficient reperfusion in patients with high thrombus burden treated with PPCI and manual aspiration thrombectomy. Methods. From January 2011 till December 2015, 277 STEMI patients undergoing manual aspiration thrombectomy and PPCI were selected and 202 patients with a Thrombolysis in Myocardial Infarction (TIMI) thrombus grade 4~5 were eventually involved in our study. According to a cTFC value, patients were divided into Group I (cTFC > 40), namely, insufficient reperfusion group; Group II (cTFC ≤ 40), namely, sufficient reperfusion group. Results. Univariate analysis showed that hypertension, multivessel disease, time from symptom to PCI (≧4.8 hours), and postaspiration cTFC > 40 were negative predictors for insufficient reperfusion. After multivariate adjustment, age ≧ 60 years, hypertension, time from symptom to PCI (≧4.8 hours), and postaspiration cTFC > 40 were independently associated with insufficient reperfusion in STEMI patients treated with manual aspiration thrombectomy. Upfront intracoronary GP IIb/IIIa inhibitor (Tirofiban) was positively associated with improved myocardial reperfusion. Conclusion. Fully identifying risk factors will help to improve the effectiveness of selective thrombus aspiration.

Impact of intracoronary adenosine administration during primary PCI: A meta-analysis

BACKGROUND

Aim of the present study was to evaluate all randomized trials, comparing intracoronary adenosine versus placebo in STEMI patients undergoing primary PCI.

METHODS AND RESULTS

PubMed, the Cochrane Library and ISI Web of Knowledge electronic databases were scanned for eligible studies up to February 23rd 2015. The summary measure used was risk ratio (RR) with 95% confidence intervals. A total of 13 studies were eligible, including 1487 patients. Incidence of ST resolution was significantly higher in the IC adenosine group than in the placebo group (RR = 1.20 [1.05–1.38]; p = 0.008). At metaregression, a significant correlation was found between the magnitude of the adenosine-related effect on ST resolution and the mean ischemic time (p = 0.011) or the percentage of patients with the LAD as the infarct-related artery (p = 0.03). Furthermore, we found a larger increase in LVEF (p = 0.02) with a parallel reduction in the incidence of heart failure (HF) (RR = 0.50 [0.28–0.89]; p = 0.02) in the IC adenosine group. Finally, IC adenosine administration was associated with a significantly lower incidence of major adverse cardiac events (MACE) both at short- (RR = 0.62 [0.39–0.98] p = 0.04) and long-term (RR = 0.61 [0.39–0.95] p = 0.03).

CONCLUSIONS

This is the first meta-analysis demonstrating a clinical benefit for IC adenosine in hard endpoints, such as adverse cardiovascular events, in patients undergoing primary PCI.

Efficacy and Safety of Non-Vitamin K Antagonist Oral Anticoagulants versus Vitamin K Antagonist Oral Anticoagulants in Patients Undergoing Radiofrequency Catheter Ablation of Atrial Fibrillation: A Meta-Analysis

BACKGROUND

Use of the non-vitamin K antagonist oral anticoagulants (NOACs) is endorsed by current guidelines for stroke prevention in patients with atrial fibrillation (AF). However efficacy and safety of NOACs in patients undergoing catheter ablation (RFCA) of AF has not been well established yet.

OBJECTIVES

To perform a meta-analysis of all studies comparing NOACs and vitamin K antagonist oral anticoagulants (VKAs) in patients undergoing RFCA.

DATA SOURCES

Studies were searched for in PubMed and Google Scholar databases.

STUDY ELIGIBILITY CRITERIA

Studies were considered eligible if: they evaluated the clinical impact of NOACs versus VKAs; they specifically analyzed the use of anticoagulants during periprocedural phase of RFCA; they reported clinical outcome data.

STUDY APPRAISAL AND SYNTHESIS METHODS

25 studies were selected, including 9881 cases. The summary measure used was the risk ratio (RR) with 95% confidence interval (CI). The random-effects or the fixed effect model were used to synthesize results from the selected studies.

RESULTS

There was no significant difference in thromboembolic complications (RR 1.39; p=0.13). Bleeding complications were significantly lower in the NOACs-treated arm as compared to VKAs (RR=0.67, p<0.001). Interestingly, a larger number of thromboembolic events was found in the VKAs-treated arm in those studies where VKAs had been interrupted during the periprocedural phase (RR=0.68; p=ns). In this same subgroup a significantly higher incidence of both minor (RR=0.54; p=0.002) and major bleeding (RR=0.41; p=0.01) events was recorded. Conversely, the incidence of thromboembolic events in the VKAs-treated arm was significantly lower in those studies with uninterrupted periprocedural anticoagulation treatment (RR=1.89; p=0.02).

LIMITATIONS

As with every meta-analysis, no patients-level data were available.

CONCLUSIONS AND IMPLICATIONS

The use of NOACs in patients undergoing RFCA is safe, given the lower incidence of bleedings observed with NOACs. On the other side, periprocedural interruption of VKAs and bridging with heparin is associated with a higher bleeding rate with no significant benefit on onset of thromboembolic events.

Left radial access for percutaneous coronary procedures: from neglected to performer? A meta-analysis of 14 studies including 7,603 procedures

BACKGROUND

Radial artery is currently the preferred access route for percutaneous coronary procedures. The major reason for its widespread use is the higher safety as compared to femoral artery access. Initially most centers have preferred the right radial artery. However, an advantage has been hypothesized for the left radial access especially for the more favorable vascular anatomy. For this reason, the aim of the present meta-analysis was to compare procedural performance of left and right radial artery access for percutaneous coronary interventions.

METHODS

We performed a meta-analysis of all available studies comparing right radial access and left radial access for coronary procedures. Corrected standardized mean difference (Hedges' g) and odds ratios (OR) were used to estimate the mean effect respectively for continuous variables and frequencies.

RESULTS

The present analysis includes 14 studies with 7603 procedures. A statistically significant difference in the amount of contrast medium utilized for the procedure (0.12 [0.03-0.21], p=0.007), in fluoroscopy time (0.16 [0.06-0.25], p=0.001) and in total procedural time (0.22 [0.11; 0.33], p<0.001) was observed in favor of the left radial access. At the same time, no significant difference in the rate of procedural failure was observed between the right and the left radial access routes (OR=1.01 [0.70-1.47], p=0.942).

CONCLUSIONS

Left radial access is associated to a modest yet significant reduction in fluoroscopy time, procedural time and in the amount of contrast medium administered, while failure rate was similar between right and left radial approaches.