A Bayesian meta-analysis of double kissing (DK) crush or provisional stenting for coronary artery bifurcation lesions

OBJECTIVE

Despite the development of dedicated, two-stent strategies, including the double kissing (DK) crush technique, the ideal technique for coronary artery bifurcation stenting has not been identified. We aimed to compare and determine the absolute risk difference (ARD) of the DK crush technique alone versus provisional stenting approaches for coronary bifurcation lesions, using the Bayesian technique.

METHOD

We queried PubMed/MEDLINE to identify randomized controlled trials (RCTs) that compared DK crush technique with provisional stenting for bifurcation lesions, published till January 2023. We used Bayesian methods to calculate the ARD and 95% credible interval (CrI).

RESULTS

We included three RCTs, with 916 patients, in the final analysis. The ARD of cardiac death was centered at -0.01 (95% CrI: -0.04 to 0.02; Tau: 0.02, 85% probability of ARD of DK crush vs. provisional stenting <0). ARD for myocardial infarction was centered at -0.03 (95%CrI: -0.9 to 0.03; Tau: 0.05, 87% probability of ARD of DK crush vs. provisional stenting <0). ARD for stent thrombosis was centered at 0.00 (95% CrI: -0.04 to 0.03, Tau: 0.03, 51% probability of ARD for DK crush vs. provisional stenting <0). Finally, ARD for target lesion revascularization was centered at -0.05 (95% CrI: -0.08 to -0.03, Tau: 0.02, 99.97% probability of ARD for DK crush vs. provisional stenting <0).

CONCLUSIONS

Bayesian analysis demonstrated a lower probability of cardiac death, myocardial infarction and target lesion revascularization, with DK crush compared with provisional stenting techniques, and a minimal probability of difference in stent thrombosis.

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

Social associations and cardiovascular mortality in the United States counties, 2016 to 2020

BACKGROUND

The positive aspects of social interaction on health have been described often, with considerably less attention to their negative aspect. This study aimed to assess the impact of social associations on cardiovascular mortality in the United States.

METHODS

The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) data sets from 2016 to 2020 were used to identify death records due to cardiovascular disease in the United States population aged 15 years and older. The social association rate defined as membership associations per 10,000 population, accessed from the 2020 County Health Rankings data was used as a surrogate for social participation. All United States counties were grouped into quartiles based on their social association rate; Q1 being the lowest quartile of social association, and Q4 the highest quartile. Age-adjusted mortality rate (AAMR) was calculated for each quartile. County health factor rankings for the state of Texas were used to adjust the AAMR for baseline comorbidities of county population, using Gaussian distribution linear regression.

RESULTS

Overall, the AAMR was highest in the 4th social association rate quartile (306.73 [95% CI, 305.72-307.74]) and lowest in the 1st social association rate quartile (266.80 [95% CI, 266.41-267.20]). The mortality rates increased in a linear pattern from lowest to highest social association rate quartiles. After adjustment for the county health factor ranks of Texas, higher social association rate remained associated with a significantly higher AAMR (coefficient 15.84 [95% CI, 12.78-18.89]).

CONCLUSIONS

Our study reported higher cardiovascular AAMR with higher social associations in the United States, with similar results after adjustment for County Health Rankings in the state of Texas.

Twenty-year United States national, demographic and regional mortality trends from traumatic thoracic aortic injury, 1999 to 2019

INTRODUCTION

Traumatic Thoracic Aortic Injury (TTAI) is associated with high mortality rates and is the second leading cause of death in traumatic patients. There has been a considerable advancement in the management of TTAI with novel and improved surgical procedures and imaging modalities. The aim of this study was to determine the national demographic and regional trends in mortality associated with TTAI in the United States across twenty years, 1999 to 2019.

METHODS

The multiple cause of death data on Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC-WONDER) database was utilized to query death certificates for TTAI from 1999 to 2019, in the United States. The International Classification of the Diseases, Tenth Revision (ICD-10) code S25.0 was used to identify and abstract data for TTAI related deaths. The data was further abstracted based on age, race, gender and Census-Bureau defined regions. The age-adjusted mortality rate (AAMR) per 100,000 population-year and Average Annual Percentage Change (AAPC) with 95 % Confidence Interval were computed. The JoinPoint software was utilized to compute the temporal trends in mortality based on a segmented change and AAPC calculation.

RESULTS

A total of 20,842 TTAI associated deaths occurred from 1999 to 2019 corresponding to an AAMR of 0.407(0.401-0.412) per 100,000 population-year. The overall AAMR reduced from 0.759 to 0.223 per 100,000 population-year from 1999 to 2019[average APC -6.5(-7.5; -5.5)]. The reduction was reported in both <45 age group [average APC -6.5(-7.9; -5.1)] and >45 age group [-6.2(-7.3; -5.0)]; among females [average APC -6.1(-7.8; -4.3)] and males [-6.1(-7.2; -5.0)]; among Whites [average APC -6.9(-7.8; -5.9)] and Blacks [-5.0(-7.4; -2.5)]. The reduction in mortality as per the census region was highest in the west followed by Mid-West, North-East and South [average APC -6.8(-8.6; -5.0); -6.2(-8.8; -3.6); -5.7(-7.0; -4.4); -5.5(-7.4; -3.6), respectively].

CONCLUSION

There was a significant decrease in the TTAI associated mortality trends in the United States across 1999-2019 with a consistent decline in all demographic and regional subgroups.

Association of sleep duration with atrial fibrillation/flutter mortality in the United States: a cross-sectional analysis

BACKGROUND

The association between sleep duration and atrial fibrillation risk is poorly understood, with inconsistent findings reported by several studies. We sought to assess the association between long sleep duration and mortality due to atrial fibrillation/atrial flutter (AF/AFL).

METHODS

The 2016-2020 Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research dataset was used to identify death records secondary to AF/AFL in the United States population. We used the 2018 Behavioral Risk Factor Surveillance System (BRFSS) dataset of sleep duration at the county level. All counties were grouped into quartiles based on the percentage of their population with long sleep duration (i.e., ≥ 7 h), Q1 being the lowest and Q4 the highest quartile. Age-adjusted mortality rates (AAMR) were calculated for each quartile. County Health Rankings for Texas were used to adjust the AAMR for comorbidities using linear regression.

RESULTS

Overall, the AAMR for AF/AFL were highest in Q4 (65.9 [95% CI, 65.5-66.2] per 100,000 person-years) and lowest in Q1 (52.3 [95% CI, 52.1-52.5] per 100,000 person-years). The AAMR for AF/AFL increased stepwise from the lowest to highest quartiles of the percentage population with long sleep duration. After adjustment for the county health ranks of Texas, long sleep duration remained associated with a significantly higher AAMR (coefficient 220.6 (95% CI, 21.53-419.72, p-value = 0.03).

CONCLUSIONS

Long sleep duration was associated with higher AF/AFL mortality. Increased focus on risk reduction for AF, public awareness about the importance of optimal sleep duration, and further research to elucidate a potential causal relationship between sleep duration and AF are warranted.

Relationship between tooth type and material used in the construction of endocrowns and fracture force values: a systematic review

OBJECTIVE

The aim of this study was to summarize the results of the endocrown (EC) studies that compared tooth preparation designs, tooth types, and ceramic material types in relation to fracture force values.

MATERIALS AND METHODS

A full literature search was conducted in Web of Science, PubMed/Medline, EMBASE, Scopus, Cochrane Library, Google Scholar, and ProQuest electronic databases. The following keywords: Endocrown [(molar(s)) or (premolar(s) or (posterior teeth)] and Ceramic materials as (Lithium disilicate glass-ceramic; Zirconia; Lava Ultimate) and (fracture strength) or (fatigue) were used. Articles were manually searched utilizing their reference lists. Study selection was not restricted or limited to the time of publication, type of tested tooth, ceramic material, and EC design.

RESULTS

A total of 34 laboratory studies published between 2008 and 2023 were included in this systemic review. Twelve studies were published in the last 3 years, the mandibular molar was examined by 14 studies, and premolars in both arches were investigated, followed by premolars in both arches. Lithium disilicate glass-ceramic (LDGC) was the most used material for EC testing, followed by LAVA Ultimate and zirconia materials. The EC design with a 2 mm extension inside the pulp (14 studies) was the most used. Fracture forces of maxillary molars or premolars were nearly equal and lower than those of mandibular molars. Differences among the fracture forces of the tested ceramic materials were marginal. EC with 2 mm deep inside the pulp showed the highest fracture force.

CONCLUSIONS

Mandibular EC molars showed the highest fracture forces, followed by maxillary premolars and molars. No differences among the EC materials in the 2- and 4-mm pulpal extension designs were found, which had higher fracture forces than other designs.

Outcomes of concomitant aortic valve procedures and left ventricular assist device implantation: A systematic review and meta-analysis

BACKGROUND

Left ventricular assist device (LVAD) implantation is frequently employed in patients with end-stage heart failure. The outcomes of addressing the repair of all substantial aortic valvular disease at the time of LVAD implantation remain unclear. We sought to assess the clinical outcomes in patients undergoing LVAD implantation concomitant with aortic valve procedures (AVPs) compared with isolated LVAD implantation.

METHODS

A literature search was performed using PubMed, Embase, and Cochrane library from inception till June 2022. Primary outcomes included short-term mortality and long-term survival. Random effects models were used to compute mean differences and odds ratios with 95% confidence intervals (CIs).

RESULTS

A total of 14 observational studies (N = 52 693) met our inclusion criteria. Concomitant LVAD implantation and AVPs were associated with higher short-term mortality (OR = 1.61 [95% CI, 1.06-2.42]; p = 0.02) and mean CPBt (MD = 43.25 [95% CI, 22.95-63.56]; p < 0.0001), and reduced long-term survival (OR = 0.70 [95% CI, 0.55-0.88]; p = 0.003) compared with isolated LVAD implantation. No difference in the odds of cerebrovascular accident (OR = 1.05 [95% CI, 0.79-1.39]; p = 0.74) and mean length of hospital stay (MD = 2.89 [95% CI, -4.04 to 9.82]; p = 0.41) was observed between the two groups. On adjusted analysis, short-term mortality was significantly higher in the LVAD group with concurrent AVPs when compared with the isolated LVAD group (aHR = 1.50 [95% CI, 1.20-1.87]; p = 0.0004).

CONCLUSIONS

Concurrent AVPs were associated with higher short-term mortality and reduced long-term survival in patients undergoing LVAD implantation compared with isolated LVAD implantation.

Impact of Chronic Kidney Disease on In-Hospital Outcomes of Hospitalizations With Acute Limb Ischemia Undergoing Endovascular Therapy

PURPOSE

Studies on outcomes related to endovascular treatment (EVT) in advanced stages of chronic kidney disease (CKD) and end-stage renal disease (ESRD) among hospitalizations with acute limb ischemia (ALI) are limited.

METHODS

The Nationwide Inpatient Sample was quarried from October 2015 to December 2017 to identify the hospitalizations with ALI and undergoing EVT. The study population was subdivided into 3 groups based on their CKD stages: group 1 (No CKD, stage I, stage II), group 2 (CKD stage III, stage IV), and group 3 (CKD stage V and ESRD). The primary outcome was all-cause in-hospital mortality.

RESULTS

A total of 51 995 hospitalizations with ALI undergoing EVT were identified. The in-hospital mortality was significantly higher in group 2 (OR = 1.17; 95% CI 1.04 - 1.32, p=0.009) and group 3 (OR = 3.18; 95% CI 2.74-3.69, p<0.0001) compared with group 1. Odds of minor amputation, vascular complication, atherectomy, and blood transfusion were higher among groups 2 and 3 compared with group 1. Group 2 had higher odds of access site hemorrhage compared with groups 1 and 3, whereas group 3 had higher odds of major amputation, postprocedural infection, and postoperative hemorrhage compared with groups 1 and 2. Besides, groups 2 and 3 had lower odds of discharge to home compared with group 1. Finally, the length of hospital stay and cost of care was significantly higher with the advancing CKD stages.

CONCLUSION

Advanced CKD stages and ESRD are associated with higher mortality, worse in-hospital outcomes and higher resource utilization among ALI hospitalizations undergoing EVT.

CLINICAL IMPACT

Current guidelines are not clear for the optimum first line treatment of acute limb ischemia, especially in patients with advanced kidney disease as compared to normal/mild kidney disease patients. We found that advanced kidney disease is a significant risk factor for worse in-hospital morbidity and mortality. Furthermore, patients with acute limb ischemia and advanced kidney disease is associated with significantly higher resource utilization as compared to patients with normal/mild kidney disease. This study suggests shared decision making between treating physician and patients when considering endovascular therapy for the treatment of acute limb ischemia in patients with advanced kidney disease.

Transitions from pediatric to adult rheumatology care for juvenile idiopathic arthritis: a patient led qualitative study

Background

Juvenile idiopathic arthritis (JIA) is a childhood autoimmune disease that causes swelling and pain in at least one joint. Young people with JIA experience symptoms that persist into adulthood, and thus will undergo a transition including the o transfer of care from a pediatric rheumatologist an adult rheumatologist. Missing from the literature is research that centres the transition experience of young people with JIA in Canada. This goal of this patient-led research was to explore the experience young people with JIA through the process of transition.

Methods

Qualitative study using the Patient and Community Engaged Research (PaCER) approach. Trained patient-researchers conducted three focus groups using the Set, Collect and Reflect PaCER process. Participants, recruited via purposive and snowball sampling using research/personal networks and social media, were young people with JIA in Canada between 18 and 28 years who had experienced with the process of transition to adult care. Recordings were transcribed verbatim. Patient researchers individually coded overlapping sections of the data, and thematic analysis was conducted.

Results

In total, nine individuals participated in one or more focus groups. Three themes were identified, with sub-themes: preparedness for transition (readiness for the transfer of care, developing self-advocacy skills), continuity and breadth of care (changing relationships, culture shock, new responsibilities), need for support (social support, mental health support, and ongoing support needs – beyond the transfer of care. Peer support was a connecting concept in the support sub-themes. Transition was more than a change in primary physician but also a change in the care model and breadth of care provided, which was challenging for young people especially if they had insufficient information.

Conclusions

Transition from pediatric to adult care in rheumatology is a significant period for young people living with JIA, and this patient-led study provided insight into the experience from the perspective of young people with JIA which is critical to informing the development of supports for patients through the process. Patients, caregivers, pediatric and adult rheumatologists and members of the multi-disciplinary care team need to collaborate in terms of resources preparing for transfer, and support throughout the transition process to ensure a successful transition process.

Early outcomes of transcatheter versus surgical aortic valve implantation in patients with bicuspid aortic valve stenosis

BACKGROUND

Limited information is available on outcomes in patients with bicuspid aortic valve (BAV) stenosis undergoing transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR), as pivotal randomised trials excluded patients with BAV pathology due to anatomic complexity.

AIMS

The aim of the study was to compare early outcomes between TAVI and SAVR in patients with BAV stenosis.

METHODS

We queried the Nationwide Readmission Database (NRD) between 2016 and 2018 to identify adults who underwent TAVI or SAVR for BAV stenosis. The study's primary outcome was in-hospital mortality. Secondary outcomes were 30-day and six-month major adverse cardiovascular events (MACE). We matched both cohorts using propensity score matching, and applied logistic and Cox-proportional hazard regression to compute the odds ratio (OR), the hazard ratio (HR), and the 95% confidence interval (CI).

RESULTS

Out of 17,068 patients with BAV stenosis, 1,629 (9.5%) patients underwent TAVI and 15,439 (90.5%) underwent SAVR. After propensity score matching (PSM), we found 1,393 matched pairs. Of the matched pairs, 848 had complete six-month follow-ups. In the PSM cohort, TAVI was associated with reduced in-hospital mortality (0.7% vs 1.8%, OR: 0.35, 95% CI: 0.13-0.93; p=0.035), and a similar rate of MACE at 30 days (1% vs 1.5%, OR: 0.65, 95% CI: 0.27-1.58; p=0.343) and at six months (4.2% vs 4.9%, HR 0.86, 95% CI: 0.44-1.69; p=0.674), compared with SAVR.

CONCLUSIONS

In the propensity score-matched cohort, TAVI was associated with reduced odds of in-hospital mortality and a similar risk of 30-day and six-month MACE, supporting the feasibility of TAVI in BAV patients without a need for concurrent aortic root repair.

Meta-analysis of Incidence and outcomes of life-threatening arrhythmias in Takotsubo Cardiomyopathy

Background

Takotsubo cardiomyopathy (TC) or stress-induced cardiomyopathy is a transient heart condition that clinically resembles an acute coronary syndrome. This study aims to assess the incidence of life-threatening arrhythmias in patients with Takotsubo cardiomyopathy and evaluate the outcomes of patients with life-threatening arrhythmias (LTAs) in Takotsubo cardiomyopathy compared with those without LTA.

Methods

We comprehensively searched the PubMed, Google Scholar, and Embase databases from inception to February 2021. The primary aim of the study was to determine the incidence of LTAs in TC patients. Other outcomes of interest were the odds of in-hospital, long-term mortality, and cardiogenic shock (CS) in TC patients with LTAs versus those without LTAs. For all statistical analyses, ReviewManager and MedCalc were used.

Results

Eighteen studies were included in this study involving 55,557 participants (2,185 with LTAs and 53,372 without LTAs). The pooled incidence of LTAs in the patients of TC was found to be 6.29% (CI: 4.70–8.08%; I2 = 94.67%). There was a statistically significant increased risk of in-hospital mortality (OR = 4.74; CI: 2.24–10.04; I2 = 77%, p < 0.0001) and cardiogenic shock (OR = 5.60; CI: 3.51–8.95; I2 = 0%, p < 0.00001) in the LTA group versus the non-LTA group. LTA was not associated with long-term mortality (OR = 2.23; CI: 0.94–5.28; I2 = 53%, p = 0.07).

Conclusion

The pooled incidence of life-threatening arrhythmias in the patients of TC was found to be 6.29%. In the group of TC patients with LTAs, the odds of in-hospital mortality and CS, was higher than in the TC patients without LTAs.

Antioxidant micronutrient supplements for adult critically ill patients: A bayesian multiple treatment comparisons meta-analysis

BACKGROUND & AIMS

Antioxidant micronutrients (AxMs) have been administered to critically ill adults attempting to counteract the oxidative stress imposed during critical illness. However, results are conflicting and relative effectiveness of AxMs regimens is unknown. We conducted a Bayesian multi-treatment comparison (MTC) meta-analysis to identify the best AxM treatment regimen that will improve clinical outcomes.

METHODS

PubMed, EMBASE, Web of Science and Cochrane databases were searched from the inception of databases through August 2020. Randomized controlled trials (RCT) comparing AxMs supplementations with placebo among critically ill adults were included. Two authors assessed trial quality using Cochrane risk of bias tool and assessed certainty of evidence (CoE). A random effect model, non-informative priors Bayesian MTC meta-analysis using gemtc package in R version 3.6.2 was performed. AxMs treatment effect on clinical outcomes (mortality, infection rates, intensive care unit (ICU) and hospital stays and ventilator days) were represented by absolute risk differences (ARD) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Prior to final analysis, we repeated the search through January 2021.

RESULTS

37 RCT (4905 patients) were included with 16 direct comparisons. With respect to mortality, the ARD for "vitamin E" compared with placebo was centred at -0.19 [95%CrI: -0.54,0.16; very low CoE] and was ranked the best treatment for mortality reduction as per surface under the cumulative ranking curve (SUCRA 0.71, 95%CrI: 0.07,1.00). A combination of "selenium, zinc and copper" was ranked the best for lowest ICU stay [-9.40, 95% CrI: -20.0,1.50; low CoE]. A combination of "selenium, zinc, copper and vitamin E" was ranked the best treatment for infection risk reduction [-0.22, 95% CrI: -0.61,0.17; very low CoE]. Ventilator days were least with a combination of "selenium, zinc and manganese" [2.80, 95% CrI: -6.30,0.89; low CoE]. Hospital stay was the lowest using a combination of "selenium, zinc and copper" [-13.00, 95% CrI: -38.00,13.00; very low CoE]. There is substantial uncertainty present in the rankings due to wide and overlapping 95% CrIs of SUCRA scores for the treatments.

CONCLUSIONS

Studies on critically ill adult patients have suggested a possible beneficial effects of certain AxM supplementations over and above the recommended dietary allowance. However, evidence does not support their use in clinical practice due to the low confidence in the estimates. Current studies evaluating specific AxMs or their combinations are limited with small sample sizes.

REGISTRATION

PROSPERO, CRD42020210199.

TAKE-HOME MESSAGE

Evidence suggesting a potential benefit of AxMs use more than recommended doses in critically ill adults is weak, indicating that there is no justification for this practice.

Revascularization or optimal medical therapy for stable ischemic heart disease: A Bayesian meta-analysis of contemporary trials

BACKGROUND

The role of revascularization in patients with stable ischemic heart disease (SIHD) has been controversial, more so in the present era of drug-eluting stents.

AIMS

To examine the absolute risk difference (ARD) between revascularization plus optimal medical therapy (OMT) versus OMT alone among patients with SIHD using Bayesian approach.

METHODS

PubMed/MEDLINE and Cochrane citation indices were utilized to identify randomized controlled trials (RCTs) through March 31, 2020. Among trials comparing initial revascularization plus OMT with initial OMT alone, revascularization arm must have comprised >50% of patients receiving either percutaneous or surgical revascularization, and >50% of patients must have received aspirin and statin as OMT in both arms.

RESULTS

Seven RCTs (12,494) were included in the final analysis. The ARD of all-cause mortality for revascularization with respect to OMT was centred at -0.002 (95% CrI: -0.01; 0.01, Tau: 0.01, 67% probability of ARD of revascularization vs. OMT < 0). The ARD for cardiac mortality was centred at -0.0025 (95%CrI: -0.01; 0.01, Tau: 0.01, 77% probability of ARD of revascularization vs. OMT < 0). The ARD for MI was -0.02 (95% CrI: -0.06; 0.00, Tau: 0.02, 97% probability of ARD for revascularization vs. OMT < 0). There was 96% probability of ARD for unstable angina with revascularization vs. OMT < 0, 4.5% probability of ARD for freedom from angina with revascularization vs. OMT < 0, and 6% probability of ARD for stroke with revascularization vs. OMT < 0.

CONCLUSIONS

Bayesian analysis demonstrated minimal probability of difference in all-cause mortality and cardiac mortality in patients with SIHD who underwent revascularization compared with OMT alone. However, revascularization was associated with lower probability of MI, unstable angina, and increased freedom from angina, but a higher risk of stroke compared with OMT alone.

PROSPERO

The protocol of this systematic review and meta-analysis was registered in PROSPERO [CRD42020160540].

Contemporary Trends of Clinical Outcomes in Primary Left Ventricular Assist Device Implantation and Postprocedure High-Risk Categories

OBJECTIVE

We aimed to analyze trends of 30-day readmission and find high-risk patients associated with increased risk of mortality, resource use, and readmission after primary left ventricular assist device (LVAD) implantation. Limited data exist on the contemporary trends of readmission rates and patients at a higher risk of worse outcomes after LVAD implantation.

METHODS AND RESULTS

This is a retrospective study of adults from the Nationwide Readmission Database who underwent primary durable LVAD implantation from 2010 to 2018. The main outcomes were 30-day readmission rates and their trends in patients with primary durable LVAD implantation from 2010 to 2018. This study also sought to identify patients at the highest risk for readmission, in-hospital mortality, and resource use. A total of 31,002 adults with primary durable LVAD implantation were included in the present analysis. Overall, 3808 patients (12.3%) died and 27,168 (87.6%) were discharged alive. Of those discharged alive, 8303 patients (30.6%) were readmitted within 30 days. The trend of 30-day all-cause readmission among LVAD implantation patients remained similar from 2010 to 2018 (P = .809). The in-hospital mortality rate during the index hospitalization decreased significantly (P = .014), and the mean cost of an index hospitalization increased (P = .031) during the study period. The patients with post-LVAD in-hospital cardiac, vascular, and thromboembolic complications (ie, high-risk patients) had the highest mortality, resource use, and readmission rates compared with patients without major complications.

CONCLUSIONS

This study found that the readmission rates associated with LVAD implantation did not change from 2010 to 2018 and identified high-risk patients who may benefit from closer monitoring after primary LVAD implantation.

Echocardiography, lung ultrasound, and cardiac magnetic resonance findings in COVID-19: A systematic review

BACKGROUND

The manifestations of COVID-19 as outlined by imaging modalities such as echocardiography, lung ultrasound (LUS), and cardiac magnetic resonance (CMR) imaging are not fully described.

METHODS

We conducted a systematic review of the current literature and included studies that described cardiovascular manifestations of COVID-19 using echocardiography, CMR, and pulmonary manifestations using LUS. We queried PubMed, EMBASE, and Web of Science for relevant articles. Original studies and case series were included.

RESULTS

This review describes the most common abnormalities encountered on echocardiography, LUS, and CMR in patients infected with COVID-19.

Outcomes of Cardiac Arrest and Cardiopulmonary Resuscitation in Patients With Left Ventricular Assist Device; an Insight From a National Inpatient Sample

BACKGROUND

Outcomes of patients with implanted left ventricular assist device (LVAD) implantation experiencing a cardiac arrest (CA) are not well reported. We aimed at defining the in-hospital outcomes of patients with implanted LVAD experiencing a CA.

METHODS

The national inpatient sample (NIS) was queried using ICD9/ICD10 codes for patients older than 18 years with implanted LVAD and CA between 2010-2018. We excluded patients with orthotropic heart transplantation, biventricular assist device (BiVAD) implantation and do not resuscitate (DNR) status.

RESULTS

A total of 93,153 hospitalisations between 2010 and 2018 with implanted LVAD were identified. Only 578 of these hospitalisations had experienced CA and of those, 173 (33%) hospitalisations underwent cardiopulmonary resuscitation (CPR). The mean age of hospitalisations that experienced a CA was 60.61±14.85 for non-survivors and 56.23±17.33 for survivors (p=0.14). The in-hospital mortality was 60.8 % in hospitalisations with CA and 74.33% in hospitalisations in whom CPR was performed. In an analysis comparing survivors with non-survivors, non-survivors had more diabetes mellitus (DM) (p=0.01), and ischaemic heart disease (IHD) (p=0.04). Age, female sex, peripheral vascular disease and history of coronary artery bypass graft (CABG) were independently associated with increased mortality in our cohort. Also, ventricular tachycardia (VT) and CPR were independently associated with in-hospital mortality. During the study period, there was a significantly decreasing trend in performing CPR in LVAD hospitalisations with CA.

CONCLUSION

In conclusion, age, female sex, peripheral vascular disease, history of CABG, VT and CPR were independently associated with in-hospital mortality in LVAD hospitalisations who experienced CA.

Frequency, Trend, Predictors, and Impact of Gastrointestinal Bleeding in Atrial Fibrillation Hospitalizations

Anticoagulation alone or in combination with other treatment strategies are implemented to reduce the risk of stroke in patients with atrial fibrillation (AF). Gastrointestinal bleeding (GIB) is a common complication of oral anticoagulation with a prevalence of 1% to 3% in patients on long term oral anticoagulation. We analyzed the national inpatient sample database from the year 2005 to 2015 to report evidence on the frequency, trends, predictors, clinical outcomes, and economic burden of GIB among AF hospitalizations. A total of 34,260,000 AF hospitalizations without GIB and 1,846,259 hospitalizations with GIB (5.39%) were included. The trend of AF hospitalizations with GIB per 100 AF hospitalizations remained stable from the year 2005 to 2015 (p value = 0.0562). AF hospitalizations with GIB had a higher frequency of congestive heart failure, long term kidney disease, long term liver disease, anemia, and alcohol abuse compared with AF hospitalizations without GIB. AF hospitalizations with GIB had a higher odds of in-hospital mortality (Odds ratio (OR) 1.47; 95% Confidence interval (CI): 1.46 to 1.48, p-value <0.0001), mechanical ventilation (OR 1.69; 95% CI: 1.68 to 1.70, p-value <0.0001), and blood transfusion (OR 7.2; 95% CI: 7.17 to 7.22, P-value <0.0001) compared with AF hospitalizations without GIB. AF hospitalizations with GIB had a lower odds of stroke (OR 0.51; 95% CI: 0.51 to 0.52, p-value <0.0001) compared with AF hospitalizations without GIB. Further, AF hospitalizations with GIB had a higher median length of stay and cost of hospitalization compared with AF hospitalizations without GIB. In conclusion, the frequency of GIB is 5.4% in AF hospitalizations and the frequency of GIB remained stable in the last decade as shown in this analysis. When GIB occurs, it is associated with higher resource utilization. This study addresses a significant knowledge gap highlighting national temporal trends of GIB and associated outcomes in AF hospitalizations.

Intracoronary brachytherapy for the treatment of recurrent drug-eluting stent in-stent restenosis: A systematic review and meta-analysis

BACKGROUND

We performed a meta-analysis on observational studies since randomized control trials are not available. We studied intracoronary brachytherapy (ICBT) and recurrent drug eluting stent in-stent restenosis (DES-ISR) to evaluate the procedural success, target lesion revascularization (TLR), incidence of myocardial infarction (MI) and all-cause mortality at 2 years follow-up.

AIM

To perform meta-analysis for patients undergoing ICBT for recurrent DES-ISR.

METHODS

We performed a systematic search of the PubMed/MEDLINE, Cochrane and DARE databases to identify relevant articles. Studies were excluded if intra-coronary brachytherapy was used as a treatment modality for initial ISR and studies with bare metal stents. We used a random-effect model with DerSimonian & Laird method to calculate summary estimates. Heterogeneity was assessed using I² statistics.

RESULTS

A total of 6 observational studies were included in the final analysis. Procedural angiographic success following intra-coronary brachytherapy was 99.8%. Incidence of MI at 1-year was 2% and 4.1% at 2-years, respectively. The incidence of TLR 14.1% at 1-year and 22.7% at 2-years, respectively. All-cause mortality at 1- and 2-year follow-up was 3% and 7.5%, respectively.

CONCLUSION

Given the observational nature of the studies included in the analysis, heterogeneity was significantly higher for outcomes. While there are no randomized controlled trials or definitive guidelines available for recurrent ISR associated with DES, this analysis suggests that brachytherapy might be the alternative approach for recurrent DES-ISR. Randomized controlled trials are required to confirm results from this study.

Meta-Analysis of Transcatheter Aortic Valve Implantation in Patients With Stenotic Bicuspid Versus Tricuspid Aortic Valve

Most of the trials investigating the role of transcatheter aortic valve implantation (TAVI) across various strata of risk categories have excluded patients with bicuspid aortic stenosis (BAS) due to its anatomical complexities. The aim of this study was to perform a meta-analysis with meta-regression of studies comparing clinical, procedural, and after-procedural echocardiographic outcomes in BAS versus tricuspid aortic stenosis (TAS) patients who underwent TAVI. We searched the PubMed and Cochrane databases for relevant articles from the inception of the database to October 2019. Continuous and categorical variables were pooled using inverse variance and Mantel-Haenszel method, respectively, using the random-effect model. To rate the certainty of evidence for each outcome, we used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach. Nineteen articles were included in the final analysis. There was no difference in the risk of 30-day mortality, 1-year mortality, 30-day cardiovascular mortality, major and/or life-threatening bleeding, major vascular complications, acute kidney injury, permanent pacemaker implantation, device success, annular rupture, after-procedural aortic valve area, and mean pressure gradient between the 2 groups. BAS patients who underwent TAVI had a higher risk of 30-day stroke, conversion to surgery, need for second valve implantation, and moderate to severe paravalvular leak. In conclusion, the present meta-analysis supports the feasibility of TAVI in surgically ineligible patients with BAS. However, the incidence of certain procedural complications such as stroke, conversion to surgery, second valve implantation, and paravalvular leak is higher among BAS patients compared with TAS patients, which must be discussed with the patient during the decision-making process.

National rates and trends of tobacco and substance use disorders among atrial fibrillation hospitalizations

BACKGROUND

Atrial Fibrillation (AF) has been associated with various behavioral risk factors such as tobacco, alcohol, and/or substances abuse.

OBJECTIVE

The main objective is to describe the national trends and burden of tobacco and substance abuse in AF hospitalizations. Also, this study identifies potential population who are more vulnerable to these substance abuse among AF hospitalizations.

METHODS

The National Inpatient Sample database from 2007 to 2015 was utilized and the hospitalizations with AF were identified using the international classification of disease, Ninth Revision, Clinical Modification code. They were stratified into without abuse, tobacco use disorder (TUD), substance use disorder (SUD), alcohol use disorder (AUD) and drug use disorder (DUD).

RESULTS

Of 3,631,507 AF hospitalizations, 852,110 (23.46%) had TUD, 1,851,170 (5.1%) had SUD, 155,681 (4.29%) had AUD and 42,667 (1.17%) had DUD. The prevalence of TUD, SUD, AUD, and DUD was substantially increased across all age groups, races, and gender during the study period. Female sex was associated with lower odds TUD, SUD, AUD, and DUD. Among AF hospitalizations, the black race was associated with higher odds of SUD, and DUD. The younger age group (18-35 years), male, Medicare/Medicaid as primary insurance, and lower socioeconomic status were associated with increased risk of both TUD and SUDs.

CONCLUSION

TUD and SUD among AF hospitalizations in the United States mainly affects males, younger individuals, white more than black, and those of lower socioeconomic status which demands for the development of preventive strategies to address multilevel influences.

Gender and Disparity in First Authorship in Cardiology Randomized Clinical Trials

This cross-sectional study assesses the annual proportions and overall trend of female first authors in cardiology randomized clinical trials from 2011 to 2020.

Comparison of procedural outcomes in patients undergoing catheter vs surgical ablation for atrial fibrillation and heart failure with reduced ejection fraction

BACKGROUND

There is a lack of research comparing procedural outcomes of surgical ablation (SA) and catheter ablation (CA) among patients with heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF). The main objective was to compare the short-term procedural outcomes of SA and CA in patients with HFrEF.

METHODS

We used the national inpatient sample to identify hospitalizations over 18 years with HFrEF hospitalization and AF, and undergoing SA and CA from 2016 to 2017. Furthermore, the clinical outcomes of SA vs CA in AF stratified as nonparoxysmal and paroxysmal were analyzed.

RESULTS

A total of 1,770 HFrEF hospitalizations with AF who underwent SA and 1,620 HFrEF hospitalizations with AF who underwent CA were included in the analysis. Hospitalizations with CA had higher baseline comorbidities. The in-hospital mortality among HFrEF with AF undergoing SA as compared with CA was similar (2.8% vs 1.9%, respectively, adjusted P-value 0.09). Hospitalizations with SA had a significantly longer length of hospital stay, a higher percentage of postprocedural, and cardiac complications. In HFrEF hospitalizations with nonparoxysmal AF, SA as compared with CA was associated with a higher percentage of in-hospital mortality (2.4% vs 1%, adjusted P-value <.05), a longer length of stay, a higher cost of treatment, and a higher percentage of cardiac complications.

CONCLUSION

CA is associated with lower in-hospital adverse procedural outcomes as compared with SA among HFrEF hospitalizations with AF. Further research with freedom from AF as one of the outcome is needed between two groups for HFrEF.

Index of microvascular resistance and outcomes following intra-coronary thrombolysis with percutaneous intervention in STEMI: a meta-analysis of randomized control trials

Microvascular obstruction following percutaneous coronary intervention (PCI) is highly prevalent and independently associated with adverse clinical outcomes. Microvascular obstruction is determined by index of the microvascular resistance. We performed a systematic review with meta-analysis of all published randomized clinical trials (RCTs) studying the effect of intra-coronary thrombolysis with PCI as compared to standard treatment among patients with ST-segment elevated myocardial infarction. We included 6 RCTs summing up to 947 patients in the final analysis. Intra-coronary thrombolysis resulted in significantly lower index of microvascular resistance [standardized mean difference: - 13.74, 95% confidence interval (CI): - 16.74 to - 10.73, P value < 0.001, I² = 0%]. There was no difference noted in the occurrence of major adverse cardiac events with intra-coronary thrombolysis as compared to standard treatment [Odds ratio:  0.71, 95% CI: 0.46-1.08, P value = 0.11,  I² = 0%]. The absence of heterogeneity deferred us from using dose-response analysis to account for altering dose used across studies. The results of the present meta-analysis highlights the role of intra-coronary thrombolysis in reducing microvascular obstruction. No effect of intra-coronary thrombolysis was noted on the occurrence of major adverse cardiac events.

Frequency, Trends, and Outcomes of Cerebrovascular Events Associated With Atrial Fibrillation Hospitalizations

The main objective is to estimate the frequency, temporal trends, and outcomes of cerebrovascular events associated with atrial fibrillation (AF) hospitalization in the United States. The national inpatient sample data was utilized to identify hospitalizations with a primary or secondary diagnosis of AF from January 1, 2005 through September 31, 2015 for the present analysis. Jonckheere-Terpstra Trend was utilized to analyze trends from 2005 to 2015. Global Wald score was used to assess relative contributions of various covariates towards stroke among AF hospitalizations. Between the years 2005 and 2015, there were 36,457,323 (95.2%) AF hospitalizations without cerebrovascular events and 1,824,608 (4.8%) with cerebrovascular events included in the final analysis. There was a statistically significant increase in the proportion of overall stroke, AIS, and AHS (p_trend value <0.001) per 1,000 AF hospitalizations. The frequency of stroke per 1,000 AF hospitalizations was highest among patients with CHA2DS2VASc score ≥3 and Charlson's comorbidity index ≥3. The trend of in-hospital mortality decreased during the study period, however, it remained higher in those with cerebrovascular events compared to those without. Lastly, hypertension, advancing age, and chronic lung disease were major stroke predicting factors among AF hospitalizations. These cerebrovascular events were associated with longer length of stay and higher costs. In conclusion, the incidence of cerebrovascular events associated with AF hospitalizations remained significantly high and the trend continues to ascend despite technological advancements. Strategies should improve to reduce the risk of AF-related stroke in the United States.

A Systematic Review of the Cardiovascular Manifestations and Outcomes in the Setting of Coronavirus-19 Disease

The impact of coronavirus disease, 2019 (COVID-19), has been profound. Though COVID-19 primarily affects the respiratory system, it has also been associated with a wide range of cardiovascular (CV) manifestations portending extremely poor prognosis. The principal hypothesis for CV involvement is through direct myocardial infection and systemic inflammation. We conducted a systematic review of the current literature to provide a foundation for understanding the CV manifestations and outcomes of COVID-19. PubMed and EMBASE databases were electronically searched from the inception of the databases through 27 April 2020. A second literature review was conducted to include major trials and guidelines that were published after the initial search but before submission. The inclusion criteria for studies to be eligible were case reports, case series, and observation studies reporting CV outcomes among patients with COVID-19 infection. This review of the current COVID-19 disease and CV outcomes literature revealed a myriad of CV manifestations with potential avenues for treatment and prevention. Future studies are required to understand on a more mechanistic level the effect of COVID-19 on the myocardium and thus provide avenues to improve mortality and morbidity.

Oral anticoagulant monotherapy compared to oral anticoagulant plus single anti-platelet therapy in stable ischemic heart disease with atrial fibrillation: a meta-analysis

Introduction

Evidence for antithrombotic therapy regimen in patients with concurrent stable ischemic heart disease (SIHD) and atrial fibrillation (AF) is not well established. The ideal regimen needs to been balanced to prevent thrombotic and embolic events, without increasing the risk of bleeding tendencies. Two randomized control trials have been published studying oral anticoagulant monotherapy (OAC) as compared to oral anticoagulant plus single antiplatelet therapy (OAC+SAPT), of which one trial was terminated prematurely and was underpowered.

Purpose

We performed a meta-analysis of RCTs and observational studies comparing OAC monotherapy to OAC+ SAPT in SIDH patients with AF.

Methods

We performed a systematic search of the PubMed, EMBASE and Cochrane databases to identify relevant articles. The database search was performed from the inception of the databases to January 2020. Inclusion criteria were RCTs and observation studies comparing OAC to OAC+SAPT in SIDH patients with AF and reporting time to event outcomes of major bleeding or cardiovascular mortality. The definition of major bleeding as per the definition provided by individual studies. Two authors independently performed data extraction to check for reproducibility. We used inverse variance method with random effect model to calculate hazard ratio (HR) with 95% confidence interval (CI). Statistical heterogeneity was calculated using Higgins I2 statistics. All statistical analysis was performed using RevMan Version 5.3 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014).

Results

Seven studies (2 RCTs and 5 observational studies) were included in the final analysis. OAC+ SAPT as compared to OAC monotherapy in patients with SIHD and AF was associated with a higher incidence of major bleeding [HR: 1.59, 95% CI: 1.36–1.85, P value&lt;0.05, I2: 0%] [Figure 1, Panel A]. OAC+SPT as compared to OAC monotherapy was associated with similar incidence of cardiovascular mortality [HR: 1.07, 95% CI: 0.86–1.33, P value= 0.55, I2: 32%] [Figure 1, Panel B]. There was no statistical heterogeneity associated with either pooled estimates.

Conclusion

OAC monotherapy as compared to OAC+SAPT in patients with SIHD and AF was associated with a lower incidence of major bleeding and similar incidence of cardiovascular mortality.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impella versus intra-aortic balloon pump in cardiogenic shock: a meta-analysis assessing 30-days mortality

Introduction

Cardiogenic shock is linked with eminent morbidity and mortality despite advances in treatment modality. Adjuvant treatment modalities to provide mechanical haemodynamic support in the form of intra-aortic balloon pump (IABP) or Impella are being used among patients with cardiogenic shock. The Impella prunes left ventricular preload, whereas, IABP persuades after load reduction and both contribute to improved cardiac output. A few underpowered randomised control trials (RCTs) and observational studies compared short term mortality benefit of Impella juxtaposed to IABP among patients with cardiogenic shock.

Purpose

A meta-analysis of RCTs and observational studies researching the short-term mortality in cardiogenic shock comparing Impella to IABP was executed.

Methods

The databases PubMed, EMBASE and Cochrane were searched systematically to identify relevant RCTs and observational studies contrasting Impella to IABP and reporting 30-days mortality as outcomes. The search terms used were “Impella”, “IAPB”, “intra-aortic balloon pump” and all word variations were utilised. The search was conducted from the debut of the databases up to January 2020. Two reviewers independently and in tandem performed data screening and extraction from identified articles. Inverse variance method with Paule-Mandel estimator for tau2 and Hartung-Knapp adjustment was used to calculate Risk Ratio with 95% confidence interval. Heterogeneity was assessed using I2 statistics. Furthermore, we calculated the 95% predictive interval for the pooled estimate. All statistical analysis for this meta-analysis was carried out using R statistical software version 3.6.2 using the package meta ( ). Additionally, Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria were used to assess the certainty of evidence.

Results

Five studies constituting 728 patients were included in the final analysis. Two were RCTs (ISAR-SHOCK trial and IMPRESS in Severe Shock trial), one study was a propensity score matched observational study and two were unmatched observational studies. There was no difference in the risk of 30-days mortality in patients treated with Impella as compared to IABP [Risk Ratio: 0.97, 95% confidence interval: 0.66–1.41, I2: 32%]. To account for the heterogeneity, we calculated 95% predictive interval: 0.46–2.02. Thus, very low certainty of evidence concluded no difference in the risk of 30-days mortality among cardiogenic shock patients treated with Impella in opposition to IABP.

Conclusion

This meta-analysis comparing Impella juxtaposed with IABP demonstrated no difference in the risk of 30-days mortality among patients with cardiogenic shock.

30-days Mortality

Funding Acknowledgement

Type of funding source: None

Mortality benefit with remote ischemic preconditioning in STEMI: a frequentist and Bayesian meta-analysis of randomized controlled trials

Introduction

Myocardial infarction related morbidity and mortality remains substantial despite perpetual improvement in patient care. Remote ischemic preconditioning among patients with myocardial infarction has exhibited to improve surrogate markers of ischemia. However, its effect on all-cause mortality is not well established.

Purpose

An updated frequentist and Bayesian meta-analysis of randomised control trials [RCTs] investigating remote ischemic preconditioning among patients with ST segment elevation myocardial infarction [STEMI] and its effect on all-cause mortality.

Methods

A systematic search across PubMed, EMBASE and Cochrane databases was performed. The inclusion criteria was RCTs comparing remote ischemic preconditioning with standard treatment juxtaposed to standard treatment alone among patients with STEMI and reporting all-cause mortality. Data extraction was carried out by two independent authors and looked for reproducibility. Inverse variance method with Paule-Mandel estimator for tau2 and Hartung-Knapp adjustment was used to calculate Risk Ratio with 95% confidence interval. Heterogeneity was assessed using I2 statistics. We estimated the robustness of our pooled effect size using Bayesian meta-analysis. A weakly informative prior [normal (0, 1) for intercept and uniform (0, 2) for standard deviation] and 20000 iterations [10000 warm-up + 10000 sampling] were used for Bayesian meta-analysis. We used meta ( ) and brm ( ) package in R for frequentist and Bayesian meta-analysis, respectively. All statistical analysis was carried out using R statistical software version 3.6.2. The certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Results

Five RCTs comprising a total of 6043 patients [3010 intervention and 3033 controls] were included in the final analysis. The largest included RCT was the CONDI-2/ERIC-PPCI 2019 trial. Remote ischemic preconditioning among patients with STEMI had no effect on all-cause mortality at follow-up [RR=0.70, 95% confidence interval = 0.26–1.87, I2=60%] [Figure 1, Panel A]. Similar results were obtained from hierarchical Bayesian meta-analysis [RR=0.55, 95% credibility interval = 0.23–1.38] [Figure 1, Panel B]. Low certainty of evidence as per GARDE, reports no benefit of remote ischemic preconditioning in reducing the risk of all-cause mortality in STEMI.

Conclusion

Remote ischemic preconditioning among patients with STEMI has no effect on all-cause mortality at follow-up.

Figure 1

Funding Acknowledgement

Type of funding source: None

Abbreviated Dual Antiplatelet Therapy Followed by P2Y12 Inhibitor Monotherapy versus 12 Months' Dual Antiplatelet Therapy Post Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

An increased incidence of stent thrombosis after implantation of first-generation drug-eluting stents led to a recommendation of dual antiplatelet therapy (DAPT) for 12 months after the procedure. However, given the use of second-generation and newer drug-eluting stents, this recommendation needs to be revisited. Several randomized controlled trials (RCTs) have studied an abbreviated DAPT regimen of ≤ 3 months followed by P2Y₁₂ inhibitor monotherapy, and results have been conflicting.

OBJECTIVE

We performed a systematic review with meta-analysis of RCTs of abbreviated DAPT for ≤ 3 months followed by P2Y₁₂ monotherapy compared with 12 months of DAPT.

METHODS

We performed a systematic search of the MEDLINE/PubMed, Cochrane, and DARE (Database of Abstracts of Reviews of Effects) databases for eligible RCTs. Quantitative analysis was performed based on the intention-to-treat principle. We used the Mantel-Haenszel method with a random-effects model to calculate relative risks (RRs) with 95% confidence intervals (CIs).

RESULTS

The final analysis included four RCTs. We found no difference in the risk of all-cause mortality (RR 0.90; 95% CI 0.77-1.05; p = 0.18; I² = 0%; χ²p = 0.58), myocardial infarction (RR 0.99; 95% CI 0.86-1.15; p = 0.85; I² = 0%; χ²p = 0.70), stroke (RR 1.14; 95% CI 0.65-1.98; p = 0.65; I² = 59%; χ²p = 0.06), or stent thrombosis (RR 0.98; 95% CI 0.73-1.33; p = 0.90; I² = 0%; χ²p = 0.48). Additionally, there was no difference in the risk for major bleeding, defined as BARC (Bleeding Academic Research Consortium) type 3 or 5, between the two groups (RR 0.62; 95% CI 0.37-1.05; p = 0.07; I² = 79%; χ²p < 0.05).

CONCLUSION

Abbreviated DAPT followed by P2Y₁₂ monotherapy resulted in a similar risk of re-ischemic clinical outcomes post percutaneous coronary intervention as compared with the standard 12-month DAPT regimen. The risk of major bleeding (BARC type 3 or 5) also remained similar between the two groups. However, as trials have reported benefits with abbreviated DAPT followed by P2Y₁₂ monotherapy in terms of combined endpoints and all bleeding (BARC type 2-5), additional research is needed.

Percutaneous mitral valve repair for secondary mitral valve regurgitation: A systematic review and meta-analysis

BACKGROUND

The first two randomized control trials (RCTs) studying the role of MitraClip in patients with secondary mitral regurgitation (MR) had antagonizing results. We, therefore, performed an updated meta-analysis of RCTs and propensity score-matched observational studies investigating the role of MitraClips in patients with secondary MR. A novel method of Kaplan Meier Curve reconstruction from derived individual patient data will be used to compare the survival probability of control groups in COAPT and MITRA HF trail, and hence, access inter-study heterogeneity.

METHODS

Medline and Cochrane databases was used for systematic search. We used the Mantel-Haenszel method with a random-effect model to calculate risk ratio (RR) with 95% confidence interval (CI) and inverse variance method with a random-effect model to calculate the mean difference (MD) with 95% confidence interval (CI). We used a fixed-effect approach for meta-regression.

RESULTS

MitraClip reduced the risk of all-cause mortality [RR: 0.72, CI: 0.55-0.95, P value = 0.02, I2 = 55%, χ²P-value = 0.08] and readmission [RR: 0.62, CI: 0.42-0.92, P value = 0.02, I² = 90%, χ²P-value<0.01] at two years follow-up. There was no effect of MitraClip on change in cardiovascular mortality and 6 m walking distance at 12 months follow-up. Meta-regression indicated left ventricular end diastolic volume and age among the factors affecting outcomes. Reconstructed Kaplan Meier curves confirmed considerable heterogeneity among patients randomized in MITRA HF and COAPT trial.

CONCLUSION

The present meta-analysis confirms the beneficial role of percutaneous mitral valve repair in patients with secondary MR. However, all the results were associated with considerable heterogeneity.

Antioxidant micronutrient supplementation in critically ill adults: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

The role of antioxidant micronutrient (AxM) supplementation in the critically ill patients has been controversial, and recent trials have suggested a tendency to harm. Therefore, we performed a systematic review with meta-analysis and trial sequential analysis (TSA) of randomized controlled trials (RCT) to examine the effect of AxM supplementation on clinical outcomes among critically ill adults.

METHODS

PubMed, EMBASE, Cochrane, CINAHL, LILACS, DARE, SCOPUS, and Web of sciences databases were searched from inception to March 2019. RCTs that compared AxM supplements with placebo in adult critically ill patients and reporting mortality as an outcomes were included. Trial quality was assessed using updated cochrane risk of bias (RoB-II) tool. Primary outcome was all-cause mortality. Secondary outcomes were 28-day mortality, intensive care unit (ICU) and hospital length of stay (LOS), ventilator days and infection between the two groups. Outcomes were summarised using random-effects estimators. Quality of evidence (QOE) was rated using Grading of Recommendations, Assessment, Development and Evaluation. Prior to final analysis, we repeated the search through September 2019. R version 3.6.2 and STATA version 13 were used for all statistical analyses.

RESULTS

Pooled analysis of 34 trials with 4678 patients revealed that AxM supplementation was associated with possible reduction in all-cause mortality (relative risk [RR], 0.89 [95%CI 0.79 to 0.99], TSA adjusted CI 0.77 to 1.03; Low QOE). Fragility index and number needed to treat were 1 and 41, respectively. Eight studies with low RoB (RR, 1.08; 95%CI 0.95 to 1.23; TSA CI, 0.64 to 1.82; moderate QOE) did not show mortality reduction with AxM supplementation.

SECONDARY OUTCOMES

ICU LOS (weighted mean difference [WMD], -0.84; 95%CI -1.50 to -0.18; moderate QOE), hospitalization days (WMD, -2.83; 95%CI -3.91to -1.75; low QOE) and ventilator days (WMD, -1.87; 95%CI -3.60 to -0.14; very low QOE) showed a statistically significant benefit with AxM supplementation. In meta-regression analysis, neither the duration of AxM therapy nor the dosage of selenium, which was the most widely studied AxM, reported an association with mortality.

CONCLUSION

Although AxM supplementation was associated with possible reduction in all-cause mortality, results from the TSA and studies with low RoB showing null effect suggest that the evidence of benefit is questionable. Secondary outcomes attained statistically significant benefit with AxM supplements, but the certainity of evidence was low. To summarize, current evidence does not justify administration of AxM in critically ill patients.

REGISTRATION

PROSPERO, CRD42019125898.

Association Between Past Hepatitis B Infection and Ischemic Heart Disease: An Analysis From the 2007-2016 NHANES Data

BACKGROUND

Infection is postulated as a possible risk factor for ischemic heart disease with a spiralling body of evidence. Hepatitis B is one of the most comprehensively investigated infection for its association with ischemic heart disease. This study aims at establishing an association between Hepatitis B core antibody status and ischemic heart disease using National Health and Nutrition Examination Survey (NHANES) database.

METHODS

NHANES data from 2007 to 2016 were used for the present analysis. To identify patients with self-reported coronary heart disease, angina/angina pectoris, myocardial infarction, we examined the answers to questions MCQ160c, MCQ160d, MCQ160e delineated in NHANES data. These questions as described in the NHANES dataset are as follows: MCQ160c-Has a doctor or other health professional ever told you that you had coronary heart disease?, MCQ160d-Has a doctor or other health professional ever told you that you had angina, also called angina pectoris?, MCQ160e- Has a doctor or other health professional ever told you that you had a heart attack also called myocardial infarction?. Next, to identify patients with positive Hepatitis B core antibody, we examined the variable LBXHBC of the NHANES dataset. Baseline characteristics, along with unadjusted and adjusted odds ratio using multivariable logistic regression analysis, of included patients were analyzed for Hepatitis B core antibody and its association with ischemic heart disease.

RESULTS

A total of 3,248 individuals with ischemic heart disease and 42,345 individuals with no ischemic heart disease were included in the final analysis. Hepatitis B core antibody positive status was associated with lower incidence of ischemic heart disease, adjusted odds ratio of 0.61 (95% confidence interval: 0.41-0.92, P value < 0.02).

CONCLUSIONS

In conclusion, the present analysis points toward a possible association between past Hepatitis B infection and ischemic heart disease. Hepatitis B infection was associated with a decreased incidence of ischemic heart disease. Further research with better design and possible molecular mechanism is warranted.

Inferior vena cava filters reduce symptomatic but not fatal pulmonary emboli after major trauma: a meta-analysis with trial sequential analysis

INTRODUCTION

The prophylactic use of inferior vena cava filters among patients with major trauma is researched by several controlled studies with contradicting results. We performed an updated meta-analysis with trial sequential analysis of controlled studies probing the prophylactic use of inferior cava filters on the development of symptomatic and fatal pulmonary embolism (PE) in patients with major trauma.

METHODS

A systematic electronic search across PubMed, Cochrane and DARE databases was executed from the debut of the databases up to September 15, 2019 for pertinent articles. The inclusion criteria being, controlled trials (randomized/ observational) investigating the prophylactic inferior vena cava filter placement among patients with major trauma juxtaposed to controls and reporting PE. Major trauma was defined as an injury severity score (ISS) > 15 or any trauma delaying the initiation of pharmacological venous thromboembolic [VTE] prophylaxis.

RESULTS

A total of ten studies were included in the final analysis, of which two were randomized control trials. The use of prophylactic inferior vena cava filters was associated with a reduced risk of symptomatic PE among subjects with major trauma, RR: 0.27, CI 0.12-0.58, P value < 0.05, I² = 0%, χ² p-value = 0.85, the evidence was further reinforced by a trial sequential analysis. However, the use of inferior vena cava filters was not associated with a decreased risk of fatal PE among subjects with major trauma, RR: 0.29, CI 0.08-1.10, P value = 0.07, I² = 0%, χ² p-value = 0.73.

CONCLUSION

The use of inferior vena cava filters curtailed the risk of symptomatic PE, the result further strengthened by trial sequential analysis. However, the present evidence fails to delineate a beneficial role of prophylactic inferior vena cava filter placement in reducing fatal PE among patients with major trauma. The possibility of Type II error cannot be excluded from this estimate.

Role of antibiotic envelopes in preventing cardiac implantable electronic device infection: A meta-analysis of 14 859 procedures

INTRODUCTION

We conducted an updated meta-analysis assessing the role of antibiotic envelopes in preventing Cardiac implantable electronic devices (CIED)-related infections as compared to standard infection prevention strategies.

METHODS

A systematic search was conducted on Medline/PubMed and EMBASE/Ovid database. We used Mantel-Haenszel method with fixed-effect model to compute risk ratio (RR) with 95% confidence interval (CI). We also performed subgroup and trial sequential analysis on the data.

RESULTS

Antibiotic envelope reduced the risk of both all infections [RR: 0.41, CI: 0.31-0.54, P < .05, I 2 = 75%, χ 2 P < .05] and major infections [RR: 0.48, CI: 0.32-0.70, P < .05, I 2 = 60%, χ 2 P = .04].

CONCLUSION

Prophylactic use of antibiotic envelopes as an adjuvant therapy to standard infection prevention strategies, helps in reducing the risk of CIED infections.

Meta-analysis Comparing Combined Use of Eicosapentaenoic Acid and Statin to Statin Alone

Role of omega-3-Fatty acids, especially eicosapentaenoic acid (EPA), in reducing cardiovascular events is not clear. We conducted a meta-analysis including trial sequential analysis (TSA) of all available randomized controlled trials (RCTs) assessing the impact of EPA + statin on cardiovascular risk reduction. The aim is to appraise cardiovascular risk reduction with EPA and statin taken together. A comprehensive search of PubMed and EMBASE databases was conducted for all RCTs that compared EPA + Statin versus statin alone and included outcomes related to cardiovascular health. We calculated a comprehensive odds ratio (ORs) and 95% confidence intervals (CIs) using a random-effects model. We included 5 RCTs totaling 27,415 patients. Our results demonstrated that EPA + statin resulted in 18% reduction in the incidence of MACE (OR = 0.78; 95% CI: 0.65 to 0.93, I² = 54%, p value <0.01) and 30% reduction in myocardial infarction (MI) (OR = 0.71; 95% CI: 0.61 to 0.82, I² = 0% p value <0.01) as compared with statin alone. With respect to MACE, the number needed to treat was 49. The statistical significance for reduction in the incidence of MACE with EPA+ statin was further augmented with trial sequential analysis. However, combined therapy of EPA + statin demonstrated no significant association on incidence of stroke when compared with statin alone or all-cause mortality. In conclusion, this meta-analysis demonstrated that EPA significantly reduced the incidence of MACE when combined with statin therapy, which is mainly driven by a significant reduction in myocardial infarction.