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Current Problems in Cardiology Oct 2023Twelve CCI patients were studied with confirmed or suspected COVID-19 infection. The majority of these patients were males (83.3%) with a median age of 55 years from... (Review)
Review
Twelve CCI patients were studied with confirmed or suspected COVID-19 infection. The majority of these patients were males (83.3%) with a median age of 55 years from three geographical locations, constituting the Middle East (7), Spain (3), and the USA (1). In 6 patients, IgG/IgM was positive for COVID-19, 4 with high pretest probability and 2 with positive RT-PCR. Type 2 DM, hyperlipidemia, and smoking were the primary risk factors. Right-sided neurological impairments and verbal impairment were the most common symptoms. Our analysis found 8 (66%) synchronous occurrences. In 58.3% of cases, neuroimaging showed left Middle Cerebral Artery (MCA) infarct and 33.3% right. Carotid artery thrombosis (16.6%), tandem occlusion (8.3%), and carotid stenosis (1%) were also reported in imaging. Dual antiplatelet therapy (DAPT) and anticoagulants were conservative therapies (10). Two AMI patients had aspiration thrombectomy, while three AIS patients had intravenous thrombolysis/tissue plasminogen activator (IVT-tPA), 2 had mechanical thrombectomy (MT), and 1 had decompressive craniotomy. Five had COVID-19-positive chest X-rays, whereas 4 were normal. four of 8 STEMI and 3 NSTEMI/UA patients complained chest pain. LV, ICA, and pulmonary embolism were further complications (2). Upon discharge, 7 patients (70%) had residual deficits while 1 patient unfortunately died.
Topics: Female; Humans; Male; Middle Aged; Anticoagulants; COVID-19; Infarction, Middle Cerebral Artery; Stroke; Thrombectomy; Thrombolytic Therapy; Tissue Plasminogen Activator; Treatment Outcome; Case Reports as Topic
PubMed: 37209804
DOI: 10.1016/j.cpcardiol.2023.101814 -
World Neurosurgery May 2023Randomized controlled trials comparing endovascular thrombectomy (EVT) versus EVT preceded by intravenous thrombolysis (EVT + IVT) for acute ischemic stroke due to... (Review)
Review
BACKGROUND
Randomized controlled trials comparing endovascular thrombectomy (EVT) versus EVT preceded by intravenous thrombolysis (EVT + IVT) for acute ischemic stroke due to large artery occlusion remain controversial. This systematic review and meta-analysis seek to compare these 2 modalities.
METHODS
Online Protocol is available at PROSPERO (york.ac.uk) (registration# CRD42022357506). MEDLINE, PubMed, and Embase were searched. The primary outcome was 90-day modified Rankin scale (mRS) ≤2. Secondary outcomes were 90-day mRS ≤1, 90-day mean mRS, National Institutes of Health Stroke Scale (NIHSS) at 1-3 and 3-7 days, 90-day Barthel Index, 90-day EQ-5D-5L (EuroQoL Group 5-Dimension 5-Level), the volume of infarction (mL), successful reperfusion, complete reperfusion, recanalization, 90-day mortality, any intracranial hemorrhage (ICH), symptomatic ICH, embolization in new territory, new infarction, puncture site complications, vessel dissection, and contrast extravasation. The certainty in the evidence was determined by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.
RESULTS
Six randomized controlled trials yielding 2332 patients were included, of which 1163 and 1169 underwent EVT and EVT + IVT, respectively. The relative risk (RR) of 90-day mRS ≤2 was similar between the groups (RR = 0.96[0.88, 1.04]; P = 0.28). EVT was non-inferior to EVT + IVT because the lower bond of 95% confidence interval of the risk difference (RD = -0.02 [-0.06, 0.02]; P = 0.36) exceeded the -0.1 non-inferiority margin. The certainty in the evidence was high. The RR of successful reperfusion (RR = 0.96 [0.93, 0.99]; P = 0.006), any ICH (RR = 0.87 [0.77, 0.98]; P = 0.02), and puncture site complications (RR = 0.47 [0.25, 0.88]; P = 0.02) were lower with EVT. For EVT + IVT, the number needed to treat for successful reperfusion was 25, and the number needed to harm for any ICH was 20. The 2 groups were similar in other outcomes.
CONCLUSION
EVT is non-inferior to EVT + IVT. In centers capable of both EVT and IVT, if timely EVT is feasible, it is reasonable to skip bridging IVT and keep rescue thrombolysis at the discretion of the interventionist for patients presenting within 4.5 hours of anterior ischemic stroke.
PubMed: 37201784
DOI: 10.1016/j.wneu.2023.05.033 -
American Journal of Transplantation :... Aug 2023Intracardiac thrombosis and/or pulmonary thromboembolism (ICT/PE) is a rare but devastating complication during liver transplantation. Its pathophysiology remains poorly... (Meta-Analysis)
Meta-Analysis
Intracardiac thrombosis and/or pulmonary thromboembolism (ICT/PE) is a rare but devastating complication during liver transplantation. Its pathophysiology remains poorly understood, and successful treatment remains a challenge. This systematic review summarizes the available published clinical data regarding ICT/PE during liver transplantation. Databases were searched for all publications reporting on ICT/PE during liver transplantation. Data collected included its incidence, patient characteristics, the timing of diagnosis, treatment strategies, and patient outcomes. This review included 59 full-text citations. The point prevalence of ICT/PE was 1.42%. Thrombi were most often diagnosed during the neohepatic phase, particularly at allograft reperfusion. Intravenous heparin was effective in preventing early-stage thrombus from progressing further and restoring hemodynamics in 76.32% of patients it was utilized for; however, the addition of tissue plasminogen activator or sole use of tissue plasminogen activator offered diminishing returns. Despite all resuscitation efforts, the in-hospital mortality rate of an intraoperative ICT/PE was 40.42%, with nearly half of these patients dying intraoperatively. The results of our systematic review are an initial step for providing clinicians with data that can help identify higher-risk patients. The clinical implications of our results warrant the development of identification and management strategies for the timely and effective treatment of these tragic occurrences during liver transplantation.
Topics: Humans; Tissue Plasminogen Activator; Liver Transplantation; Thrombosis; Pulmonary Embolism; Heart Diseases
PubMed: 37156300
DOI: 10.1016/j.ajt.2023.04.029 -
Frontiers in Endocrinology 2023Intravenous recombinant tissue plasminogen activator (rtPA) thrombolysis is an effective treatment for acute ischemic stroke. Hyperglycemia is a major risk factor for... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND OBJECTIVES
Intravenous recombinant tissue plasminogen activator (rtPA) thrombolysis is an effective treatment for acute ischemic stroke. Hyperglycemia is a major risk factor for the occurrence, development, and prognosis of ischemic stroke. This meta-analysis purposefully estimates the association between hyperglycemia and poor prognosis in acute ischemic stroke patients receiving intravenous rtPA thrombolytic therapy.
MATERIALS AND METHODS
According to the predefined inclusion criteria, we searched PubMed, Web of Science, and Cochrane Library databases. The association of high blood glucose(>140mg/dl) with symptomatic intracranial hemorrhage (sICH), poor clinical outcome and mortality at 90 days post-rtPA thrombolysis was studied using both a common effects model and a random effects model. Odds ratios (ORs) were plotted on forest plots.
RESULTS
Of a total cohort of 2565 patients who received intravenous thrombolytic therapy, 721 had higher blood glucose. High glucose level significantly increased the odds of sICH (OR 1.80; 95% confidence interval(95%CI): 1.30- 2.50) and poor clinical outcome at 90 days (OR 1.82; 95%CI: 1.52-2.19), and all-cause mortality at 90 days (OR 2.51; 95%CI:1.65-3.82).
CONCLUSIONS
In our meta-analysis, high blood glucose was significantly associated with sICH, poor clinical outcome and higher mortality at 90 days.
Topics: Humans; Tissue Plasminogen Activator; Stroke; Blood Glucose; Ischemic Stroke; Brain Ischemia; Fibrinolytic Agents; Prognosis; Thrombolytic Therapy; Intracranial Hemorrhages; Hyperglycemia
PubMed: 37124754
DOI: 10.3389/fendo.2023.1120779 -
Phytotherapy Research : PTR Jun 2023In patients with acute ischemic stroke (AIS), the effect of salvianolic acids for injection (SAFI) as the secondary treatment after intravenous thrombolysis (IVT) is... (Meta-Analysis)
Meta-Analysis Review
Effects of intravenous thrombolysis with and without salvianolic acids for injection on the functional recovery of patients with acute ischemic stroke: A systematic review, meta-analysis, and trial sequential analysis.
In patients with acute ischemic stroke (AIS), the effect of salvianolic acids for injection (SAFI) as the secondary treatment after intravenous thrombolysis (IVT) is unclear. We aimed to evaluate the efficacy of SAFI for patients with AIS undergoing IVT. We searched seven electronic databases and two registries from inception to July 24, 2022, for randomized controlled trials (RCTs) assessing the effect of SAFI plus recombinant tissue plasminogen activator (rt-PA) on the functional recovery compared to rt-PA alone in patients with AIS. Two independent authors selected RCTs, extracted data, and assessed the risk of bias. A meta-analysis was conducted. Eight RCTs involving 682 patients with AIS were included. Compared to patients receiving intravenous rt-PA alone, those receiving intravenous rt-PA combined with SAFI had a higher likelihood of achieving favorable functional outcomes at 3 months. In addition, the use of SAFI for 2 weeks was associated with better neurological recovery. The evidence of benefit was confirmed by trial sequential analysis (TSA). The incidence of intracranial hemorrhage did not differ between the two groups. In patients with AIS, intravenous rt-PA combined with SAFI might achieve better functional outcomes. However, further high-quality studies are needed to firmly establish the clinical efficacy of SAFI.
Topics: Humans; Stroke; Brain Ischemia; Thrombolytic Therapy; Tissue Plasminogen Activator; Ischemic Stroke; Treatment Outcome; Fibrinolytic Agents
PubMed: 37092721
DOI: 10.1002/ptr.7843 -
Neurological Sciences : Official... Sep 2023We aimed to evaluate the available evidence on the efficacy and safety outcomes of intravenous tenecteplase (TNK) compared with intravenous alteplase(ALT) for patients... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
We aimed to evaluate the available evidence on the efficacy and safety outcomes of intravenous tenecteplase (TNK) compared with intravenous alteplase(ALT) for patients with acute ischemic stroke (AIS) in randomized controlled trials (RCTs).
METHODS
The MEDLINE/PubMed, Embase, Springer, Web of Science, Cochrane Collaboration database, China National Knowledge Infrastructure (CNKI) database, and Wanfang database were comprehensively searched for RCTs regarding the effects of TNK versus ALT among AIS patients in these English and Chinese electronic databases from inception dates to August 1, 2022. This meta-analysis followed PRISMA guidelines. Two reviewers independently retrieved RCTs and extracted relevant information. The methodological quality of the included trials was estimated using the Cochrane risk of bias tool. The pooled analyses were performed using RevMan 5.3 software. The primary outcome was functional outcome on the modified Rankin Scale (mRS) (range 0 to 5) and mortality at 90 days. The secondary outcomes included successful recanalization, early neurologic improvement < 48 h, any intracranial hemorrhage (ICH), and symptomatic ICH. The follow-up time of all studies was at least 3 months.
RESULTS
A total of nine RCTs involving 1958 patients in TNK group and 1731 patients in ALT group were finally included. For the efficacy outcomes, there were no significant differences between the two groups in terms of mRS score 0 ~ 2 (RR 1.00; 95% CI 0.88-1.13; P = 0.96), mRS score 0 ~ 1 (RR 1.03; 95% CI 0.96-1.10; P = 0.36), successful recanalization (RR 1.25; 95% CI 0.88-1.76; P = 0.21), and early neurologic improvement < 48 h (RR 1.08; 95% CI 0.92-1.26; P = 0.37). Similar results were seen for the safety outcomes, which have no statistical differences in terms of any ICH (RR 1.01; 95% CI 0.72-1.41; P = 0.96), symptomatic ICH (RR 1.19; 95% CI 0.81-1.76; P = 0.37), and mortality at 90 days (RR 0.99; 95% CI 0.83-1.19; P = 0.94).
CONCLUSION
Overall, the efficacy and safety outcomes of intravenous thrombolysis with TNK versus ALT for AIS were not statistically different. However, TNK at a dose of 0.25 mg/kg may be a reasonable alternative to ALT for thrombolysis.
Topics: Humans; Tissue Plasminogen Activator; Tenecteplase; Fibrinolytic Agents; Stroke; Intracranial Hemorrhages; Ischemic Stroke; Thrombolytic Therapy; Treatment Outcome; Brain Ischemia
PubMed: 37061572
DOI: 10.1007/s10072-023-06801-0 -
Angiology Mar 2024Pulmonary embolism (PE) is the third-leading cause of cardiovascular mortality and the second-leading cause of death in cancer patients. The clinical efficacy of... (Review)
Review
Pulmonary embolism (PE) is the third-leading cause of cardiovascular mortality and the second-leading cause of death in cancer patients. The clinical efficacy of thrombolysis for acute PE has been proven, yet the therapeutic window seems narrow, and the optimal dosing for pharmaceutical reperfusion therapy has not been established. Higher doses of systemic thrombolysis inevitably associated with an incremental increase in major bleeding risk. To date, there is no high-quality evidence regarding dosing and infusion rates of thrombolytic agents to treat acute PE. Most clinical trials have focused on thrombolysis compared with anticoagulation alone, but dose-finding studies are lacking. Evidence is now emerging that lower-dose thrombolytic administered through a peripheral vein is efficacious in accelerating thrombolysis in the central pulmonary artery and preventing acute right heart failure, with reduced risk for major bleeding. The present review will systematically summarize the current evidence of low-dose thrombolysis in acute PE.
Topics: Humans; Thrombolytic Therapy; Pulmonary Embolism; Fibrinolytic Agents; Hemorrhage; Treatment Outcome; Acute Disease
PubMed: 37060258
DOI: 10.1177/00033197231167062 -
World Neurosurgery Jul 2023To determine the cost-effectiveness of mechanical thrombectomy (MT) versus best medical management (BMM) in patients aged ≥80 years.
OBJECTIVE
To determine the cost-effectiveness of mechanical thrombectomy (MT) versus best medical management (BMM) in patients aged ≥80 years.
METHODS
We performed a systematic literature review to identify comparative studies of MT versus BMM with or without intravenous tissue-type plasminogen activator (IV tPA) in patients ≥80 years. Clinical data including outcomes and mortality categorized as modified Rankin scale scores 0-2, 3-5, and 6, were collected from identified studies, and effectiveness scores were assigned to each outcome. Costs associated with stroke outcomes were derived from previous literature, including costs associated with initial and follow-up imaging, hospitalization, physicians/associated personnel, and MT. TreeAge Pro software was used to construct a cost-effectiveness analysis model of clinical data from studies and costs derived from the literature.
RESULTS
The review identified 1 relevant comparative study. The cost model demonstrated total annual cumulative overall per-patient costs of $30,064.21 for BMM with IV tPA and $21,940.36 for BMM without IV tPA. Overall effectiveness scores were 0.61 and 0.62, respectively. MT had a cumulative total annual per-patient cost of $47,849.54 and an overall effectiveness score of 0.40. The cost-effectiveness ratios of total cumulative patient cost to overall outcome effectiveness score for the 3 treatments were as follows: BMM with IV tPA = $49,285.59, BMM without IV tPA = $35,387.58, and MT = $119,623.85. BMM with or without IV tPA was found to be more cost-effective than MT.
CONCLUSIONS
This study utilized stroke outcomes data for patients aged ≥80 years to conduct a cost-effectiveness analysis. MT was found to be less cost-effective than BMM with and without IV tPA.
Topics: Aged; Humans; Ischemic Stroke; Cost-Effectiveness Analysis; Thrombectomy; Tissue Plasminogen Activator; Stroke; Administration, Intravenous; Treatment Outcome; Brain Ischemia; Fibrinolytic Agents; Cost-Benefit Analysis; Thrombolytic Therapy
PubMed: 37037370
DOI: 10.1016/j.wneu.2023.04.012 -
Annals of Agricultural and... Mar 2023In COVID-19, the rapid prediction of the severity of a patient's condition using modern biomarkers can accelerate the implementation of appropriate therapy, and thus... (Meta-Analysis)
Meta-Analysis
INTRODUCTION AND OBJECTIVE
In COVID-19, the rapid prediction of the severity of a patient's condition using modern biomarkers can accelerate the implementation of appropriate therapy, and thus improve the patient's prognosis.
MATERIAL AND METHODS
A meta-analysis was conducted of data available in the literature on the differences in baseline suPAR blood concentration between patients (1) who tested positive and negative for COVID-19, (2) who had severe and non-severe COVID-19, and (3) COVID-19 survivors and non-survivors.
RESULTS
SuPAR levels in SARS-CoV-2 negative and positive patients varied and amounted to 3.61±1.59 ng/ml vs. 6.45±3.13 ng/ml, respectively (MD = -3.18; 95%CI: -4.71 to -1.66; p<0.001). suPAR levels among non-severe and severe COVID-19 patients were 7.06±2.64 ng/ml and 5.06±3.16 ng/ml (MD = 0.18; 95%CI: -2.48 to 2.83; p=0.90), respectively. Pooled analysis showed that suPAR levels between severe versus critical COVID-19 patients to be 5.59±1.54 ng/ml and 6.49±1.43 ng/ml, respectively (MD = -1.00; 95%CI: -1.31 to -0.70; p<0.001). The suPAR levels between ICU survivors versus non-survivors amounted to 5.82±2.33 ng/ml and 8.43±4.66 ng/ml (MD = -3.59; 95%CI: -6.19 to -1.00; p=0.007). In the case of in-hospital mortality, the mean suPAR level among survivors to hospital discharge was 5.63±1.27 ng/ml, compared to 7.85±2.61 ng/ml for patients who did not survive (MD = -3.58; 95%CI: -5.42 to -1.74; p<0.001).
CONCLUSIONS
SuPAR levels are significantly elevated in severe COVID-19 illness and maybe useful in predicting mortality. Further studies are needed to determine cut-off points and clarify the association of suPAR levels with disease progression. This is of utmost importance given the ongoing pandemic and overburdened health care systems.
Topics: Humans; Receptors, Urokinase Plasminogen Activator; COVID-19; SARS-CoV-2; Disease Progression; Biomarkers
PubMed: 36999867
DOI: 10.26444/aaem/160084 -
Stroke May 2023Prior systematic reviews have compared the efficacy of intravenous tenecteplase and alteplase in acute ischemic stroke, assigning their relative complications as a... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Prior systematic reviews have compared the efficacy of intravenous tenecteplase and alteplase in acute ischemic stroke, assigning their relative complications as a secondary objective. The objective of the present study is to determine whether the risk of treatment complications differs between patients treated with either agent.
METHODS
We performed a systematic review including interventional studies and prospective and retrospective, observational studies enrolling adult patients treated with intravenous tenecteplase for ischemic stroke (both comparative and noncomparative with alteplase). We searched MEDLINE, Embase, the Cochrane Library, Web of Science, and the www.
CLINICALTRIALS
gov registry from inception through June 3, 2022. The primary outcome was symptomatic intracranial hemorrhage, and secondary outcomes included any intracranial hemorrhage, angioedema, gastrointestinal hemorrhage, other extracranial hemorrhage, and mortality. We performed random effects meta-analyses where appropriate. Evidence was synthesized as relative risks, comparing risks in patients exposed to tenecteplase versus alteplase and absolute risks in patients treated with tenecteplase.
RESULTS
Of 2226 records identified, 25 full-text articles (reporting 26 studies of 7913 patients) were included. Sixteen studies included alteplase as a comparator, and 10 were noncomparative. The relative risk of symptomatic intracranial hemorrhage in patients treated with tenecteplase compared with alteplase in the 16 comparative studies was 0.89 ([95% CI, 0.65-1.23]; I=0%). Among patients treated with low dose (<0.2 mg/kg; 4 studies), medium dose (0.2-0.39 mg/kg; 13 studies), and high dose (≥0.4 mg/kg; 3 studies) tenecteplase, the RRs of symptomatic intracranial hemorrhage were 0.78 ([95% CI, 0.22-2.82]; I=0%), 0.77 ([95% CI, 0.53-1.14]; I=0%), and 2.31 ([95% CI, 0.69-7.75]; I=40%), respectively. The pooled risk of symptomatic intracranial hemorrhage in tenecteplase-treated patients, including comparative and noncomparative studies, was 0.99% ([95% CI, 0%-3.49%]; I=0%, 7 studies), 1.69% ([95% CI, 1.14%-2.32%]; I=1%, 23 studies), and 4.19% ([95% CI, 1.92%-7.11%]; I=52%, 5 studies) within the low-, medium-, and high-dose groups. The risks of any intracranial hemorrhage, mortality, and other studied outcomes were comparable between the 2 agents.
CONCLUSIONS
Across medium- and low-dose tiers, the risks of complications were generally comparable between those treated with tenecteplase versus alteplase for acute ischemic stroke.
Topics: Humans; Tissue Plasminogen Activator; Tenecteplase; Fibrinolytic Agents; Ischemic Stroke; Prospective Studies; Retrospective Studies; Stroke; Intracranial Hemorrhages; Treatment Outcome; Brain Ischemia
PubMed: 36951049
DOI: 10.1161/STROKEAHA.122.042335