Outcomes of left ventricular thrombosis in post-acute myocardial infarction patients stratified by antithrombotic strategies: A meta-analysis with meta-regression

Cardiovascular Outcomes in Acute Coronary Syndrome and Malnutrition: A Meta-Analysis of Nutritional Assessment Tools

Background

There is emerging evidence that malnutrition is associated with poor prognosis among patients with acute coronary syndrome (ACS).

Objectives

This study seeks to elucidate the prognostic impact of malnutrition in patients with ACS and provide a quantitative review of most commonly used nutritional assessment tools.

Methods

Medline and Embase were searched for studies reporting outcomes in patients with malnutrition and ACS. Nutritional screening tools of interest included the Prognostic Nutrition Index, Geriatric Nutritional Risk Index, and Controlling Nutritional Status. A comparative meta-analysis was used to estimate the risk of all-cause mortality and cardiovascular events based on the presence of malnutrition and stratified according to ACS type, ACS intervention, ethnicity, and income.

Results

Thirty studies comprising 37,303 patients with ACS were included, of whom 33.5% had malnutrition. In the population with malnutrition, the pooled mortality rate was 20.59% (95% CI: 14.95%-27.67%). Malnutrition was significantly associated with all-cause mortality risk after adjusting for confounders including age and left ventricular ejection fraction (adjusted HR: 2.66, 95% CI: 1.78-3.96, P = 0.004). There was excess mortality in the group with malnutrition regardless of ACS type (P = 0.132), ethnicity (P = 0.245), and income status (P = 0.058). Subgroup analysis demonstrated no statistically significant difference in mortality risk between individuals with and without malnutrition (P = 0.499) when using Controlling Nutritional Status (OR: 7.80, 95% CI: 2.17-28.07, P = 0.011), Geriatric Nutritional Risk Index (OR: 4.30, 95% CI: 2.78-6.66, P < 0.001), and Prognostic Nutrition Index (OR: 4.67, 95% CI: 2.38-9.17, P = 0.023).

Conclusions

Malnutrition was significantly associated with all-cause mortality risk following ACS, regardless of ACS type, ethnicity, and income status, underscoring the importance of screening and interventional strategies for patients with malnutrition.

Surgical Transmitral Thrombectomy to Prevent Recurrent Stroke in Acute Myocardial Infarction

Left ventricular (LV)-thrombi occur in up to 14 % of patients with acute myocardial infarction (AMI) in the era of primary percutaneous coronary intervention. For these patients, anticoagulant therapy (AC) is recommended by AMI-guidelines. When, despite AC, LV-thrombi lead to embolism, surgical thrombectomy is an option, which is not mentioned or not recommended in AMI-guidelines. We report a 46-year old female patient with AMI. An 80 % stenosis of the proximal left anterior descending coronary artery was treated by a drug-eluting stent. Thrombi within the akinetic LV-apex became mobile despite AC and dual antiplatelet therapy, and a cerebellar stroke occurred. By a transmitral surgical approach with endoscopic assistance the thrombi were completely removed. Postoperative course and 12-months follow-up were uneventful. LV-thrombi should be observed carefully regarding changes in morphology. Surgical thrombectomy of LV-thrombi is a rare treatment option to prevent imminent embolism. Benefits versus risks of surgical removal of LV-thrombi need to be carefully weighted.

What's the optimal duration of anticoagulation in patients with left ventricular thrombus?

INTRODUCTION

Left ventricular thrombus (LVT) occurs in acute myocardial infarction and in ischemic and non-ischemic cardiomyopathies. LVT may result in embolic stroke. Currently, the duration of anticoagulation for LVT is unclear. This is an important clinical question as prolonged anticoagulation is associated with increased bleeding risks, while premature discontinuation may result in embolic complications.

AREAS COVERED

There are no randomized trial data regarding anticoagulation duration for LVT. Guidelines and expert consensus recommend anticoagulation for 3-6 months with cessation of anticoagulation if interval imaging demonstrates thrombus resolution. Cardiac magnetic resonance imaging (CMR) is more sensitive and specific compared to echocardiography for LVT detection, and may be appropriate for high-risk patients. Prolonged anticoagulation may be considered in unresolved protuberant or mobile LVT, and in patients with resolved LVT but persistent depressed left ventricular ejection fraction and/or myocardial akinesia or dyskinesia.

EXPERT OPINION

CMR will likely be increasingly used for LVT surveillance to guide anticoagulation duration. Further research is needed to determine which patients with persistent LVT on CMR benefit from prolonged anticoagulation.

A Meta-Analysis on the Global Prevalence, Risk factors and Screening of Coronary Heart Disease in Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

Cardiovascular disease remains the leading cause of death in patients with nonalcoholic fatty liver disease (NAFLD). Studies examining the association of coronary heart disease (CHD) and NAFLD are cofounded by various cardiometabolic factors, particularly diabetes and body mass index. Hence, we seek to explore such association by investigating the global prevalence, independent risk factors, and influence of steatosis grade on manifestation of CHD among patients with NAFLD.

METHODS

Two databases, Embase and Medline, were utilized to search for articles relating to NAFLD and CHD. Data including, but not limited to, continent, diagnostic methods, baseline characteristics, prevalence of CHD, CHD severity, NAFLD severity, and risk factors were extracted.

RESULTS

Of the 38 articles included, 14 reported prevalence of clinical coronary artery disease (CAD) and 24 subclinical CAD. The pooled prevalence of CHD was 44.6% (95% confidence interval [CI], 36.0%-53.6%) among 67,070 patients with NAFLD with an odds ratio of 1.33 (95% CI, 1.21%-1.45%; P &lt; .0001). The prevalence of CHD was higher in patients with moderate to severe steatosis (37.5%; 95% CI, 15.0%-67.2%) than those with mild steatosis (29.6%; 95% CI, 13.1%-54.0%). The pooled prevalence of subclinical and clinical CAD was 38.7% (95% CI, 29.8%-48.5%) and 55.4% (95% CI, 39.6%-70.1%), respectively.

CONCLUSION

Steatosis was found to be related with CHD involvement, with moderate to severe steatosis related to clinical CAD. Early screening and prompt intervention for CHD in NAFLD are warranted for holistic care in NAFLD.

Risk factors for in-hospital systemic thromboembolism in myocardial infarction patients with left-ventricular thrombus: A multicenter retrospective study

Left-ventricular thrombus (LVT) is a potentially life-threatening disease. However, few studies have explored the risk factors of in-hospital systemic thromboembolism (ST) in LVT patients. In this multicenter retrospective study, we enrolled myocardial infarction patients with LVT from January 2008 to September 2021. Multivariable logistic regression analysis was applied to identify the independent risk factors for ST in LVT patients. A total number of 160 hospitalized LVT patients [median follow-up period 50 months (18.3-82.5 months)] were subjected to analysis. Of them, 54 (33.8%) patients developed acute myocardial infarction, 16 (10%) had ST, and 33 (20.6%) died. Comparable baseline characteristics were established between the ST and non-ST groups, except for the heart failure classification (P = .014). We obtained the following results from our multivariable analysis, based on the use of HFrEF as a reference: HFpEF [odd ratio (OR), 6.2; 95% confidence interval (CI), 1.4-26.3; P = .014] and HFmrEF (OR, 5.0; 95%CI, 1.1-22.2; P = .033). In conclusion, HFpEF, and HFmrEF may be independent risk factors for in-hospital ST development.

Global prevalence of depression and anxiety in patients with hepatocellular carcinoma: Systematic review and meta-analysis

BACKGROUND/AIMS

Depression and anxiety are associated with poorer outcomes in patients with hepatocellular carcinoma (HCC). However, the prevalence of depression and anxiety in HCC are unclear. We aimed to establish the prevalence of depression and anxiety in patients with HCC.

METHODS

MEDLINE and Embase were searched and original articles reporting prevalence of anxiety or depression in patients with HCC were included. A generalized linear mixed model with Clopper-Pearson intervals was used to obtain the pooled prevalence of depression and anxiety in patients with HCC. Risk factors were analyzed via a fractional-logistic regression model.

RESULTS

Seventeen articles involving 64,247 patients with HCC were included. The pooled prevalence of depression and anxiety in patients with HCC was 24.04% (95% confidence interval [CI], 13.99-38.11%) and 22.20% (95% CI, 10.07-42.09%) respectively. Subgroup analysis determined that the prevalence of depression was lowest in studies where depression was diagnosed via clinician-administered scales (16.07%;95% CI, 4.42-44.20%) and highest in self-reported scales (30.03%; 95% CI, 17.19-47.01%). Depression in patients with HCC was lowest in the Americas (16.44%; 95% CI, 6.37-36.27%) and highest in South-East Asia (66.67%; 95% CI, 56.68-75.35%). Alcohol consumption, cirrhosis, and college education significantly increased risk of depression in patients with HCC.

CONCLUSION

One in four patients with HCC have depression, while one in five have anxiety. Further studies are required to validate these findings, as seen from the wide CIs in certain subgroup analyses. Screening strategies for depression and anxiety should also be developed for patients with HCC.

Meta-analysis of the Placebo and Nocebo Effects Associated with Placebo Treatment in Randomized Trials of Lipid Lowering Therapy

BACKGROUND

Randomized controlled trials (RCTs) of lipid-lowering therapy (LLT) in which the control groups received placebo without background LLT offer unique insights into the placebo and nocebo effects of lipid-lowering RCTs.

METHODS

Embase and Medline were searched for hyperlipidemia RCTs with placebo-controlled arms. Placebo arms with background LLT were excluded. A single arm meta-analysis of proportions was used to estimate major adverse cardiovascular events (MACE) and adverse events (AE). A meta-analysis of means was used to estimate the pooled mean differences of total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoproteins (HDL) and triglycerides.

RESULTS

A total of 40 RCTs and 37 668 placebo-treated participants were included. The pooled mean changes for TC, LDL, HDL, and triglycerides were -0.019 mmol/L, -0.028 mmol/L, 0.013 mmol/L and 0.062 mmol/L respectively among placebo-treated participants, indicating a modest placebo effect. The pooled average nocebo effect among placebo-treated participants was 42.62% for all AEs and 3.38% for musculoskeletal-related AEs, 11.36% for gastrointestinal-related AEs and 6.62% for headaches. Placebo-treated participants in secondary prevention RCTs had a far higher incidence of these nocebo effects than primary prevention RCTs: any AEs (OR 6.76, 95%CI: 5.56-8.24, P < 0.001), and gastrointestinal-related AE (OR 1.23, 95%CI: 1.00-1.51, P = 0.049). No differences in nocebo effects were found between the placebo arms of statin and non-statin trials.

CONCLUSION

Our meta-analysis of placebo-treated participants in RCTs with no background LLT indicate a modest placebo effect but prominent nocebo effect of musculoskeletal, headache and gastrointestinal symptoms that was greatest among secondary prevention RCTs. These findings may inform the design of future LLT RCTs.

A systematic review and meta-analysis on the impact of pre-existing and new-onset atrial fibrillation on outcomes before and after liver transplantation

BACKGROUND AND AIMS

Atrial Fibrillation (AF) is the most commonly diagnosed cardiac arrhythmia. It is associated with significant morbidity and mortality, as it is a major risk factor for cerebral vascular accidents (CVA). Our aim was to determine the prevalence of pre-existing and new-onset AF among patients undergoing liver transplantation (LT) and its impact on post-transplant outcomes.

METHODS

Medline and Embase were searched. Single-arm analysis was conducted using the generalized linear mixed model to determine the prevalence of pre-existing and new-onset AF. Logistic regression was performed to analyze risk factors. Comparative meta-analysis in odds ratio was conducted for binary outcomes.

RESULTS

Twenty articles were included, with 17 studies on pre-existing AF, and 7 including data on new-onset AF post-LT. The prevalence of pre-existing AF was 3.3% (CI 2.3-4.7) (14 studies, 45,070 patients) in pooled analysis. Significantly higher prevalence of pre-existing AF patients from North America was noted when compared to Europe (4.5%, CI 3.4-5.8 vs 1.5%, CI 0.8-2.7; p = 0.001). Body mass index (BMI), history of hypertension, diabetes, coronary artery disease (CAD), and cerebrovascular accidents (CVA) were risk factors for pre-existing AF. Pre-existing AF was significantly associated with major adverse cardiac or cerebrovascular events (MACCE) postoperatively (OR 8.02, 95%CI 5.40-11.90, p < 0.001). New-onset AF post-LT had an incidence of 6.8% (CI 4.9-9.3), and was associated with increased risk of mortality (OR 2.31, 95% CI 1.76-3.02, p < 0.001) and graft failure (OR 2.98, CI 1.99-4.47, p < 0.001).

CONCLUSION

AF is relatively more common among patients undergoing LT compared to the general non-transplant population. Additionally, it is associated with adverse outcomes including MACCE, thus warranting clinical attention. Thorough cardiac assessment, and close surveillance of post-operative AF may be clinically prudent.

UNOS Down-Staging Criteria for Liver Transplantation of Hepatocellular Carcinoma: Systematic Review and Meta-Analysis of 25 Studies

BACKGROUND & AIMS

Down-staging is commonly used to select patients with hepatocellular carcinoma (HCC) beyond Milan criteria (MC) for liver transplantation (LT), but outcomes are heterogenous. We aimed to estimate pooled down-staging success rates, HCC recurrence, and overall survival (OS), stratified by criteria used for baseline tumor burden.

METHODS

We searched Pubmed and EMBASE databases from inception until August 2021 for studies reporting down-staging success (reduction of tumor burden to within MC) and outcomes of adult HCC patients. In addition, we performed a pooled analysis using reconstructed individual participant data to obtain robust estimates for OS.

RESULTS

We screened 1059 articles and included 25 articles involving 3997 patients. Overall, 55.16% (45.49%-64.46%) underwent successful down-staging, and 31.52% (24.03%-40.11%) received LT (by intention-to-treat analysis [ITT]). Among patients who received LT, 16.01% (11.80%-21.37%) developed HCC recurrence. Comparing studies that used the United Network for Organ Sharing Down-Staging (UNOS-DS) criteria versus studies beyond UNOS-DS or did not specify criteria, down-staging success (by ITT) was 83.21% versus 45.93%, P < .001; the proportion who received LT (by ITT) was 48.61% vs 28.60%, P = .030; and HCC recurrence (among patients who received LT) occurred in 9.06% versus 20.42%, P < .001. Among studies that used UNOS-DS criteria, ITT 1- and 5-year OS from the initiation of down-staging treatment was 86% and 58%, respectively, whereas 1- and 5-year post-LT OS was 94% and 74%, respectively.

CONCLUSIONS

Among studies that adhered to UNOS-DS criteria, down-staging was successful in four-fifths of patients, >50% received LT, and post-LT outcomes were excellent. These data provide clinical validation for the utilization of UNOS-DS criteria.

Long-term outcomes after out-of-hospital cardiac arrest: a systematic review and meta-analysis

AIMS

Long term outcomes after out-of-hospital cardiac arrest (OHCA) are not well understood. This study aimed to evaluate the long-term (1-year and beyond) survival outcomes, including overall survival and survival with favorable neurological status and the quality-of-life (QOL) outcomes, among patients who survived the initial OHCA event (30 days or till hospital discharge).

METHODS

Embase, Medline and PubMed were searched for primary studies (randomized controlled trials, cohort and cross-sectional studies) which reported the long-term survival outcomes of OHCA patients. Data abstraction and quality assessment was conducted, and survival at predetermined timepoints were assessed via single-arm meta-analyses of proportions, using generalized linear mixed models. Comparative meta-analyses were conducted using the Mantel-Haenszel Risk Ratio (RR) estimates, using the DerSimonian and Laird model.

RESULTS

67 studies were included, and among patients that survived to hospital discharge or 30-days, 77.3% (CI=71.2-82.4), 69.6% (CI=54.5-70.3), 62.7% (CI=54.5-70.3), 46.5% (CI=32.0-61.6), and 20.8% (CI=7.8-44.9) survived to 1-, 3-, 5-, 10- and 15-years respectively. Compared to Asia, the probability of 1-year survival was greater in Europe (RR=2.1, CI=1.8-2.3), North America (RR=2.0, CI=1.7-2.2) and Oceania (RR=1.9,CI=1.6-2.1). Males had a higher 1-year survival (RR:1.41, CI=1.25-1.59), and patients with initial shockable rhythm had improved 1-year (RR=3.07, CI=1.78-5.30) and 3-year survival (RR=1.45, CI=1.19-1.77). OHCA occurring in residential locations had worse 1-year survival (RR=0.42, CI=0.25-0.73).

CONCLUSION

Our study found that up to 20.8% of OHCA patients survived to 15-years, and survival was lower in Asia compared to the other regions. Further analysis on the differences in survival between the regions are needed to direct future long-term treatment of OHCA patients.

A meta-analysis of the cumulative incidence, risk factors, and clinical outcomes associated with chronic kidney disease after liver transplantation

Chronic kidney disease (CKD) remains a relatively common complication after liver transplantation (LT), and significantly impacts overall survival. We sought to assess the cumulative incidence, risk factors and mortality associated with post-LT CKD. CKD was defined as eGFR <60 ml/min/1.73 m² as estimated by the Modified Diet in Renal Disease (MDRD) formula. Single-arm meta-analysis was done to evaluate the cumulative incidence of CKD at 1-, 3-, and 5-year timepoints post-LT. Risk factors for CKD were evaluated using hazard ratios (HR). Twenty-one studies involving 44 383 patients were included. Cumulative incidence of stage 3-5 CKD was 31.44% (CI 0.182-0.447), 36.71% (CI 0.188-0.546), and 43.52% (CI 0.296-0.574) at 1, 3, and 5 years after LT, respectively. Stage 5 CKD cumulative incidence increased from 0.274% (CI 0.001-0.005) at 1 year to 2.06% (CI 0.009-0.045) at 5 years post-LT. Age, female sex, diabetes, and peri-operative acute kidney injury (AKI) were significant risk factors for CKD. Stage 4-5 CKD was associated with a decrease in overall survival (HR 3.23, 95% CI 1.74-5.98, P < 0.01). CKD after LT is relatively common, and is associated with significantly reduced overall survival. Identification of patients at high risk of developing CKD allows physicians to prophylactically use renal-sparing immunosuppression which may be crucial in achieving desirable clinical outcomes.

A Meta-Analysis on the Incidence of Donor Related Depression after Liver Transplant

AIM

Living donor liver transplantation (LDLT) is increasing, yet gaps exist in the understanding of psychological wellbeing of donors after liver transplant. This meta-analysis seeks to evaluate the incidence and risk factors for donor-related depression after liver transplantation.

METHODS

A search was conducted on Medline and Embase database. Articles assessing incidence of depression in LDLT donors were included. Incidence was pooled after Freeman-Tukey double-arcsine transformation. For risk factors, dichotomous variables were analyzed with generalized linear model while a conventional meta regression with logit transformation was conducted for continuous variables.

RESULTS

Of 1,069 abstracts, 40 articles underwent full-text review. 17 articles were included. The pooled incidence of depression among 1,888 LT donors was 7.66% (CI: 4.47% - 12.80%). Depression rates were significantly higher in Asian compared to Western studies (RR: 1.73, CI: 1.19 - 2.52, p=0.0039). Female gender (p<0.001), Caucasian ethnicity (p=0.047), employment status (p<0.001) and lower education levels (p=0.044) were significantly associated with depression. Donor relationship with recipients was not a significant risk factor.

CONCLUSIONS

LDLT remains a core aspect of the treatment of end-stage liver disease. However, the high depression rates after LT suggest that there remains room for improvement in the care of donors' mental health post-transplant.