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European Heart Journal. Quality of Care... Jun 2023Cardiovascular disease (CVD) risk prediction is important for guiding the intensity of therapy in CVD prevention. Whilst current risk prediction algorithms use... (Meta-Analysis)
Meta-Analysis
Machine-learning versus traditional approaches for atherosclerotic cardiovascular risk prognostication in primary prevention cohorts: a systematic review and meta-analysis.
BACKGROUND
Cardiovascular disease (CVD) risk prediction is important for guiding the intensity of therapy in CVD prevention. Whilst current risk prediction algorithms use traditional statistical approaches, machine learning (ML) presents an alternative method that may improve risk prediction accuracy. This systematic review and meta-analysis aimed to investigate whether ML algorithms demonstrate greater performance compared with traditional risk scores in CVD risk prognostication.
METHODS AND RESULTS
MEDLINE, EMBASE, CENTRAL, and SCOPUS Web of Science Core collections were searched for studies comparing ML models to traditional risk scores for CVD risk prediction between the years 2000 and 2021. We included studies that assessed both ML and traditional risk scores in adult (≥18 year old) primary prevention populations. We assessed the risk of bias using the Prediction Model Risk of Bias Assessment Tool (PROBAST) tool. Only studies that provided a measure of discrimination [i.e. C-statistics with 95% confidence intervals (CIs)] were included in the meta-analysis. A total of 16 studies were included in the review and meta-analysis (3302 515 individuals). All study designs were retrospective cohort studies. Out of 16 studies, 3 externally validated their models, and 11 reported calibration metrics. A total of 11 studies demonstrated a high risk of bias. The summary C-statistics (95% CI) of the top-performing ML models and traditional risk scores were 0.773 (95% CI: 0.740-0.806) and 0.759 (95% CI: 0.726-0.792), respectively. The difference in C-statistic was 0.0139 (95% CI: 0.0139-0.140), P < 0.0001.
CONCLUSION
ML models outperformed traditional risk scores in the discrimination of CVD risk prognostication. Integration of ML algorithms into electronic healthcare systems in primary care could improve identification of patients at high risk of subsequent CVD events and hence increase opportunities for CVD prevention. It is uncertain whether they can be implemented in clinical settings. Future implementation research is needed to examine how ML models may be utilized for primary prevention.This review was registered with PROSPERO (CRD42020220811).
Topics: Adult; Humans; Adolescent; Cardiovascular Diseases; Risk Factors; Retrospective Studies; Heart Disease Risk Factors; Machine Learning; Primary Prevention
PubMed: 36869800
DOI: 10.1093/ehjqcco/qcad017 -
Primary Care Diabetes Jun 2020The publication of new trials brought additional data to the controversial topic of aspirin use in diabetic patients for primary prevention. Therefore, we aimed to... (Meta-Analysis)
Meta-Analysis
AIMS
The publication of new trials brought additional data to the controversial topic of aspirin use in diabetic patients for primary prevention. Therefore, we aimed to systematically review all randomized controlled trials evaluating the clinical impact of aspirin in this setting.
METHODS
We searched for randomized controlled trials (RCTs) evaluating the impact of aspirin in patients with diabetes in primary prevention, in MEDLINE, EMBASE, CENTRAL (November/2018). The primary outcomes were all-cause mortality and the composite outcome of major adverse cardiovascular events (MACE). A meta-analysis was performed deriving risk ratios (RR) and 95% confidence intervals (CI).
RESULTS
All-cause mortality was not significantly reduced with RR 0.96 (95% CI 0.90-1.03; 7RCT; 27,595 patients). Regarding MACE, there was an 8% risk reduction (RR 0.92, 95% CI 0.84-0.999; I=0%; 8RCT; 29,814 patients). The risks of major bleeding (RR 1.30, 95% CI 1.10-1.53; 2RCTs, 18,019 patients), and major GI bleeding (RR 1.39, 95% CI 1.08-1.80; 2RCTs, 18,019 patients) were significantly increased. The risks of cardiovascular mortality, myocardial infarction, stroke and amputation were not significantly different from control arm.
CONCLUSIONS
Aspirin use among diabetic patients in primary prevention appears was associated with increased risk of major bleeding, a modest decrease of MACE and lack of mortality benefit.
Topics: Aspirin; Cardiovascular Diseases; Diabetes Mellitus; Humans; Platelet Aggregation Inhibitors; Primary Prevention
PubMed: 31791903
DOI: 10.1016/j.pcd.2019.11.004 -
European Journal of Preventive... Feb 2022Cardiovascular disease (CVD) is the major cause of morbidity and mortality in individuals with chronic kidney disease (CKD). This study assessed the risks and benefits... (Meta-Analysis)
Meta-Analysis
AIMS
Cardiovascular disease (CVD) is the major cause of morbidity and mortality in individuals with chronic kidney disease (CKD). This study assessed the risks and benefits of aspirin in the primary prevention of CVD in individuals with CKD.
METHODS AND RESULTS
Ovid MEDLINE was searched from 2015 to 15th of September 2020 to include randomized controlled trials that assessed aspirin versus placebo in adults with non-end stage CKD without a previous diagnosis of CVD. A pre-specified protocol was registered with PROSPERO (identification number CRD42014008860). A random effects model was used to calculate a pooled hazard ratio (HR), pooled risk difference, and the number needed to treat or harm (NNT/NNH). The primary endpoint was CVD. Secondary endpoints included: all-cause mortality; coronary heart disease; stroke; and major and minor bleeding events. Five trials were identified (n = 7852 total, n = 3935 aspirin, n = 3917 placebo). Overall, 434 CVD events occurred. There was no statistically significant reduction in CVD events (HR 0.76, 95% confidence interval (CI) 0.54-1.08; P = 0.13, I2 = 63%), all-cause mortality (HR 0.94, 95% CI 0.74-1.19; P = 0.60, I2 = 21%), coronary heart disease events (HR 0.66, 95% CI 0.27-1.63; P = 0.37, I2 = 64%) or stroke (HR 0.87, 95% CI 0.6-1.27; P = 0.48, I2 = 24%) from aspirin therapy. The risk of major bleeding events were increased by approximately 50% (HR 1.53, 95% CI 1.13-2.05; P = 0.01, I2 = 0%) and minor bleeding events were more than doubled (HR 2.64, 95% CI 1.64-4.23; P < 0.01, I2 = 0%).
CONCLUSIONS
Aspirin cannot be routinely recommended for the primary prevention of CVD in individuals with CKD as there is no evidence for its benefit but there is an increased risk of bleeding.
Topics: Adult; Aspirin; Cardiovascular Diseases; Hemorrhage; Humans; Primary Prevention; Renal Insufficiency, Chronic
PubMed: 34448849
DOI: 10.1093/eurjpc/zwab132 -
The American Journal of Cardiology Nov 2023
Meta-Analysis
Topics: Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Anthracyclines; Randomized Controlled Trials as Topic; Heart Diseases; Antibiotics, Antineoplastic; Primary Prevention; Cardiotoxicity
PubMed: 37683579
DOI: 10.1016/j.amjcard.2023.08.123 -
Cardiology Journal 2023Recent data regarding the comparison of implantable cardioverter-defibrillator (ICD) therapy and optimal medical treatment in patients with non-ischemic cardiomyopathy... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Recent data regarding the comparison of implantable cardioverter-defibrillator (ICD) therapy and optimal medical treatment in patients with non-ischemic cardiomyopathy has indicated no mortality benefit as a result of ICD therapy. Although the recommendations for ICD implantation did not change, it is worth noting that these findings significantly affected the daily practice of ICD implantation in Europe.
METHODS
To assess the effect of ICD implantation in comparison to pharmacotherapy in the non- -ischemic cardiomyopathy heart failure population through a systematic review and meta-analysis of the available carefully designed prospective randomized controlled trials. Only prospective randomized controlled trials comparing ICD implantation in primary prevention vs. optimal pharmacological therapy or placebo and reporting mortality results were included in the meta-analysis. The authors have chosen to include the following trials: CAT, AMIOVIRT, DEFINITE, and DANISH.
RESULTS
A meta-analysis of pooled hazard ratios (HR) from all trials conducted on a total of 1789 patients found that ICD therapy decreased all-cause mortality in comparison to optimal pharmacological treatment, with a HR of 0.48 (95% confidence interval [CI] 0.67-1.01); p = 0.06. The data from the AMIOVIRT, DANISH, and DEFINITE trials, with a total of 1677 participants, showed a significant reduction of sudden cardiac deaths as a result of ICD implantation, with a HR of 0.48 (95% CI 0.31-0.67); p < 0.001.
CONCLUSIONS
In comparison with optimal medical treatment, ICD implantation in patients with heart failure improves the long-term prognosis in terms of sudden cardiac death, with a strong tendency towards all-cause mortality reduction.
Topics: Humans; Defibrillators, Implantable; Cardiomyopathies; Prospective Studies; Primary Prevention; Heart Failure; Myocardial Ischemia; Death, Sudden, Cardiac
PubMed: 33843044
DOI: 10.5603/CJ.a2021.0041 -
American Journal of Cardiovascular... Nov 2022The role of aspirin in cardiovascular primary prevention remains controversial. Moreover, evidence for the potential benefits of aspirin in patients with high... (Meta-Analysis)
Meta-Analysis
Benefits and Risks Associated with Low-Dose Aspirin Use for the Primary Prevention of Cardiovascular Disease: A Systematic Review and Meta-Analysis of Randomized Control Trials and Trial Sequential Analysis.
BACKGROUND
The role of aspirin in cardiovascular primary prevention remains controversial. Moreover, evidence for the potential benefits of aspirin in patients with high cardiovascular risk remains limited.
OBJECTIVE
The aim of this study was to explore the role of low-dose aspirin in primary prevention.
METHODS
The PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched for randomized clinical trials (RCTs) from the date of inception to August 2021. The efficacy outcomes were major adverse cardiovascular events (MACE), myocardial infarction (MI), ischemic stroke (IS), all-cause mortality, and cardiovascular mortality, whereas safety outcomes were major bleeding, intracranial hemorrhage, and gastrointestinal (GI) bleeding. Subgroup analyses were based on different cardiovascular risks and diabetes statuses. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using the fixed- and random-effects models, and trial sequential analysis (TSA) was conducted to determine the robustness of the results.
RESULTS
A total of 10 RCTs fulfilled the inclusion criteria. The use of aspirin was associated with a significant reduction in the risk of MACE (RR 0.89, 95% CI 0.84-0.93), MI (RR 0.86, 95% CI 0.78-0.95), and IS (RR 0.84, 95% CI 0.76-0.93); however, aspirin also increased the risk of safety outcomes, i.e. major bleeding (RR 1.42, 95% CI 1.26-1.60), intracranial hemorrhage (RR 1.33, 95% CI 1.11-1.59), and GI bleeding (RR 1.91, 95% CI 1.44-2.54). Subgroup analyses revealed that in the absence of a statistically significant interaction, a trend toward a net benefit of lower incidence of cardiovascular events (number needed to treat of MACE: high risk: 682 vs. low risk: 2191) and lesser risk of bleeding events (number needed to harm of major bleeding: high risk: 983 vs. low risk: 819) was seen in the subgroup of high cardiovascular risk. Meanwhile, the greater MACE reduction was also detected in the high-risk group of diabetes or nondiabetes patients. Furthermore, a post hoc subgroup analysis indicated a significant rate reduction in patients aged ≤ 70 years but not in patients aged > 70 years. TSA confirmed the benefit of aspirin for MACE up to a relative risk reduction of 10%.
CONCLUSION
The current study demonstrated that the cardiovascular benefits of low-dose aspirin were equally balanced by major bleeding events. In addition, the potential beneficial effects might be seen in the population ≤ 70 years of age with high cardiovascular risk and no increased risk of bleeding.
Topics: Aged; Humans; Aspirin; Cardiovascular Diseases; Diabetes Mellitus; Gastrointestinal Hemorrhage; Intracranial Hemorrhages; Myocardial Infarction; Primary Prevention; Risk Assessment
PubMed: 35570250
DOI: 10.1007/s40256-022-00537-6 -
Maturitas Dec 2022Opportunistic salpingectomy (OS) is an attractive method for primary prevention of ovarian cancer. Although OS has not been associated with a higher complication rate,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Opportunistic salpingectomy (OS) is an attractive method for primary prevention of ovarian cancer. Although OS has not been associated with a higher complication rate, it may be associated with earlier onset of menopause.
OBJECTIVE
To provide a systematic review and meta-analysis of the effect of OS on both age at menopause and ovarian reserve.
METHODS
A search was conducted in the Cochrane Library, Embase and MEDLINE databases from inception until March 2022. We included randomized clinical trials and cohort studies investigating the effect of OS on onset of menopause and/or ovarian reserve through change in anti-Müllerian hormone (AMH), antral follicle count (AFC), estradiol (E2), follicle stimulating hormone (FSH) and luteinizing hormone (LH). Data was extracted independently by two researchers. Random-effects meta-analyses were conducted to estimate the pooled effect of OS on ovarian reserve.
RESULTS
The initial search yielded 1047 studies. No studies were found investigating the effect of OS on age of menopause. Fifteen studies were included in the meta-analysis on ovarian reserve. Meta-analyses did not result in statistically significant differences in mean change in AMH (MD -0.07 ng/ml, 95%CI -0.18;0.05), AFC (MD 0.20 n, 95 % CI -4.91;5.30), E2 (MD 3.97 pg/ml, 95%CI -0.92;8.86), FSH (MD 0.33mIU/ml, 95%CI -0.15;0.81) and LH (MD 0.03mIU/ml; 95%CI -0.47;0.53).
CONCLUSION
Our study shows that OS does not result in a significant reduction of ovarian reserve in the short term. Further research is essential to confirm the absence of major effects of OS on menopausal onset since clear evidence on this subject is lacking. Registration number PROSPERO CRD42021260966.
Topics: Female; Humans; Ovarian Reserve; Ovarian Neoplasms; Follicle Stimulating Hormone; Salpingectomy; Luteinizing Hormone; Primary Prevention; Anti-Mullerian Hormone
PubMed: 36030627
DOI: 10.1016/j.maturitas.2022.08.002 -
Annals of Internal Medicine Jul 2017Implantable cardioverter-defibrillators (ICDs) have a role in preventing cardiac arrest in patients at risk for life-threatening ventricular arrhythmias. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Implantable cardioverter-defibrillators (ICDs) have a role in preventing cardiac arrest in patients at risk for life-threatening ventricular arrhythmias.
PURPOSE
To compare ICD therapy with conventional care for the primary prevention of death of various causes in adults with ischemic or nonischemic cardiomyopathy.
DATA SOURCES
MEDLINE, Cochrane Central Register of Controlled Trials, Google Scholar, and EMBASE databases, as well as several Web sites, from 1 April 1976 through 31 March 2017.
STUDY SELECTION
Randomized controlled trials, published in any language, comparing ICD therapy with conventional care and reporting mortality outcomes (all-cause, sudden, any cardiac, or noncardiac) in the primary prevention setting.
DATA EXTRACTION
2 independent investigators extracted study data and assessed risk of bias.
DATA SYNTHESIS
Included were 11 trials involving 8716 patients: 4 (1781 patients) addressed nonischemic cardiomyopathy, 6 (4414 patients) ischemic cardiomyopathy, and 1 (2521 patients) both types of cardiomyopathy. Mean follow-up was 3.2 years. An overall reduction in all-cause mortality, from 28.26% with conventional care to 21.37% with ICD therapy (hazard ratio [HR], 0.81 [95% CI, 0.70 to 0.94]; P = 0.043), was found. The magnitude of reduction was similar in the cohorts with nonischemic (HR, 0.81 [CI, 0.72 to 0.91]) and ischemic (HR, 0.82 [CI, 0.63 to 1.06]) disease, although the latter estimate did not reach statistical significance. The rate of sudden death fell from 12.15% with conventional care to 4.39% with ICD therapy (HR, 0.41 [CI, 0.30 to 0.56]), with a similar magnitude of reduction in patients with ischemic (HR, 0.39 [CI, 0.23 to 0.68]) and those with nonischemic disease (HR, 0.44 [CI, 0.17 to 1.12]). Noncardiac and any cardiac deaths did not differ significantly by treatment.
LIMITATION
Heterogeneous timing of ICD placement; heterogeneous pharmacologic and resynchronization co-interventions; trials conducted in different eras; adverse events and complications not reviewed.
CONCLUSION
Overall, primary prevention with ICD therapy versus conventional care reduced the incidence of sudden and all-cause death.
PRIMARY FUNDING SOURCE
None.
Topics: Arrhythmias, Cardiac; Cardiomyopathies; Death, Sudden; Death, Sudden, Cardiac; Defibrillators, Implantable; Humans; Myocardial Ischemia; Primary Prevention
PubMed: 28632280
DOI: 10.7326/M17-0120 -
JAMA Dec 2017Postmenopausal status coincides with increased risks for chronic conditions such as heart disease, osteoporosis, cognitive impairment, or some types of cancers.... (Review)
Review
IMPORTANCE
Postmenopausal status coincides with increased risks for chronic conditions such as heart disease, osteoporosis, cognitive impairment, or some types of cancers. Previously, hormone therapy was used for the primary prevention of these chronic conditions.
OBJECTIVE
To update evidence for the US Preventive Services Task Force on the benefits and harms of hormone therapy in reducing risks for chronic conditions.
DATA SOURCES
MEDLINE, Cochrane Library, EMBASE, and trial registries from June 1, 2011, through August 1, 2016. Surveillance for new evidence in targeted publications was conducted through July 1, 2017.
STUDY SELECTION
English-language randomized clinical trials reporting health outcomes.
DATA EXTRACTION AND SYNTHESIS
Dual review of abstracts, full-text articles, and study quality; meta-analyses when at least 3 similar studies were available.
MAIN OUTCOMES AND MEASURES
Beneficial or harmful changes in risks for various chronic conditions.
RESULTS
Eighteen trials (n = 40 058; range, 142-16 608; mean age, 53-79 years) were included. Women using estrogen-only therapy compared with placebo had significantly lower risks, per 10 000 person-years, for diabetes (-19 cases [95% CI, -34 to -3]) and fractures (-53 cases [95% CI, -69 to -39]). Risks were statistically significantly increased, per 10 000 person-years, for gallbladder disease (30 more cases [95% CI, 16 to 48]), stroke (11 more cases [95% CI, 2 to 23]), venous thromboembolism (11 more cases [95% CI, 3 to 22]), and urinary incontinence (1261 more cases [95% CI, 880 to 1689]). Women using estrogen plus progestin compared with placebo experienced significantly lower risks, per 10 000 person-years, for colorectal cancer (-6 cases [95% CI, -9 to -1]), diabetes (-14 cases [95% CI, -24 to -3), and fractures (-44 cases [95% CI, -71 to -13). Risks, per 10 000 person-years, were significantly increased for invasive breast cancer (9 more cases [95% CI, 1 to 19]), probable dementia (22 more cases [95% CI, 4 to 53]), gallbladder disease (21 more cases [95% CI, 10 to 34]), stroke (9 more cases [95% CI, 2 to 19]), urinary incontinence (876 more cases [95% CI, 606 to 1168]), and venous thromboembolism (21 more cases [95% CI, 12 to 33]).
CONCLUSIONS AND RELEVANCE
Hormone therapy for the primary prevention of chronic conditions in menopausal women is associated with some beneficial effects but also with a substantial increase of risks for harms. The available evidence regarding benefits and harms of early initiation of hormone therapy is inconclusive.
Topics: Aged; Estrogen Replacement Therapy; Estrogens; Female; Hormone Replacement Therapy; Humans; Middle Aged; Noncommunicable Diseases; Postmenopause; Practice Guidelines as Topic; Primary Prevention; Progestins; United States
PubMed: 29234813
DOI: 10.1001/jama.2017.16952 -
BMJ Open Jun 2017It is uncertain whether multiple health behaviour change (MHBC) interventions are effective for the primary prevention of cardiovascular disease (CVD) in primary care. A... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
It is uncertain whether multiple health behaviour change (MHBC) interventions are effective for the primary prevention of cardiovascular disease (CVD) in primary care. A systematic review and a meta-analysis were performed to evaluate the effectiveness of MHBC interventions on CVD risk and CVD risk factors; the study also evaluated associations of theoretical frameworks and intervention components with intervention effectiveness.
METHODS
The search included randomised controlled trials of MHBC interventions aimed at reducing CVD risk in primary prevention population up to 2017. Theoretical frameworks and intervention components were evaluated using standardised methods. Meta-analysis with stratification and meta-regression were used to evaluate intervention effects.
RESULTS
We identified 31 trials (36 484 participants) with a minimum duration of 12 months follow-up. Pooled net change in systolic blood pressure (16 trials) was -1.86 (95% CI -3.17 to -0.55; p=0.01) mm Hg; diastolic blood pressure (15 trials), -1.53 (-2.43 to -0.62; p=0.001) mm Hg; body mass index (14 trials), -0.13 (-0.26 to -0.01; p=0.04) kg/m; serum total cholesterol (14 trials), -0.13 (-0.19 to -0.07; p<0.001) mmol/L. There was no significant association between interventions with a reported theoretical basis and improved intervention outcomes. No association was observed between intervention intensity (number of sessions and intervention duration) and intervention outcomes. There was significant heterogeneity for some risk factor analyses, leading to uncertain validity of some pooled net changes.
CONCLUSIONS
MHBC interventions delivered to CVD-free participants in primary care did not appear to have quantitatively important effects on CVD risk factors. Better reporting of interventions' rationale, content and delivery is essential to understanding their effectiveness.
Topics: Cardiovascular Diseases; Health Behavior; Humans; Primary Health Care; Primary Prevention; Randomized Controlled Trials as Topic; Risk Factors
PubMed: 28619779
DOI: 10.1136/bmjopen-2016-015375