Comparative Therapeutic Assessment of Atrial Fibrillation in Heart Failure With Reduced Ejection Fraction—A Network Meta-Analysis

Optimal effectiveness of heart failure management - an umbrella review of meta-analyses examining the effectiveness of interventions to reduce (re)hospitalizations in heart failure

Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients.

Predictors of improvement of left ventricular systolic function after catheter ablation of persistent atrial fibrillation in patients with heart failure with reduced ejection fraction

Although several studies have suggested that catheter ablation (CA) of atrial fibrillation (AF) can improve left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction (HFrEF), the predictor of improvement of LVEF is unclear. A total of 401 patients with persistent AF underwent an initial CA between September 2014 and October 2019 in our hospital. Among them, we analyzed consecutive patients with moderately or severely reduced LVEF (< 50%) measured by transthoracic echocardiography (TTE) within 2 months before CA and underwent follow-up TTE during sinus rhythm at 6 months or more after CA. These patients were categorized into two groups: improve group (I group) with the absolute improvement of LVEF ≥ 10% at follow-up TTE, and non- improve group (NI group) with the absolute improvement of LVEF < 10% at follow-up TTE. We compared patient characteristics, ablation procedures, and clinical outcomes between the two groups. 81 patients were analyzed, and I group consisted of 48 patients (59%). In the univariate analysis, absence of ischemic cardiomyopathy, left ventricular end-diastolic diameter (LVEDD), and absence of recurrence of AF between 3 and 6 months after CA were associated with improvement of LVEF. A receiver operating characteristics analysis determined the suitable cut-off value for LVEDD was 53 mm (sensitivity: 62.2%, specificity: 86.2%, area under curve: 0.762). A multivariate analysis showed that LVEDD < 53 mm was independently associated with improvement of LVEF (odds ratio 2.58, 95% confidence interval 1.29-6.12; P = 0.021). In conclusion, LVEDD < 53 mm might be an independent predictor of improvement of LVEF after CA of persistent AF in HFrEF patients.

Methodological and Clinical Heterogeneity and Extraction Errors in Meta-Analyses of Catheter Ablation for Atrial Fibrillation in Heart Failure

Background

Meta‐analyses are expected to follow a standardized process, and thus, they have become highly formulaic, although there is little evidence that such regimentation yields high‐quality results.

Methods and Results

This article describes the results of a critical examination of 14 published meta‐analyses of catheter ablation for atrial fibrillation in heart failure that were based on a nearly identical core set of 4 to 6 primary trials. Methodological issues included (1) the neglect of primary data or the failure to report any primary data; (2) the inaccurate recording of the number of randomized patients; (3) the lack of attention to data missingness or baseline imbalances; (4) the failure to contact investigators of primary trials for additional data; (5) the incorrect extraction of data, the misidentification of events, and the assignment of events to the wrong treatment groups; (6) the calculation of summary estimates based on demonstrably heterogenous data, methods of differing reliability, or unrelated end points; and (7) the development of conclusions based on sparse numbers of events or overly reliant on the results of 1 dominant trial.

Conclusions

These findings reinforce existing concerns about the methodological validity of meta‐analyses and their current status in the hierarchy of medical evidence, and they raise new questions about the process by which meta‐analyses undergo peer review by medical journals.