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BMC Medical Imaging Jul 2015Patients evaluated for acute and chronic chest pain comprise a large, heterogeneous group that often provides diagnostic challenges. Although speckle tracking... (Review)
Review
BACKGROUND
Patients evaluated for acute and chronic chest pain comprise a large, heterogeneous group that often provides diagnostic challenges. Although speckle tracking echocardiography (STE) has proved to have diagnostic value in acute coronary syndrome it is not commonly incorporated in everyday practice. The purpose of the present systematic review was to assess the diagnostic accuracy of left ventricular (LV) longitudinal function by STE to predict significant coronary artery stenosis (CAD+) or not (CAD-) verified by coronary angiography in patients with chest pain suspected to be of cardiac ischemic origin.
METHODS
4 electronic databases; Embase, Medline, Cochrane and PubMed ahead-of print were searched for per 19.05.14. Only full-sized articles including >40 patients were selected.
RESULTS
A total of 166 citations were identified, 16 full-size articles were assessed of which 6 were found eligible for this review. Of 781 patients included 397 (60%) had CAD+. The overall weighted mean global longitudinal strain (GLS) was -17.2% (SD=2.6) among CAD+ vs. -19.2% (SD=2.8) in CAD- patients. Mean area under curve in 4 studies for predicting CAD+ ranged from 0.68 to 0.80. The study cut-off levels for prediction of CAD+ in the ROC analysis varied between -17.4% and -19.7% with sensitivity from 51% to 81% and specificity between 58% and 81%. In 1 study GLS obtained during dobutamine stress echocardiography (DSE) had the best accuracy. Regional strain measurements were not uniform, but may have potential in detecting CAD.
CONCLUSIONS
GLS measurements at rest only have modest diagnostic accuracy in predicting CAD+ among patients presenting with acute or chronic chest pain. The results from regional strain, layer specific strain and DSE need to be verified in larger studies.
Topics: Coronary Stenosis; Echocardiography; Elasticity Imaging Techniques; Female; Humans; Male; Reproducibility of Results; Sensitivity and Specificity; Stroke Volume; Ventricular Dysfunction, Left
PubMed: 26204938
DOI: 10.1186/s12880-015-0067-y -
Therapeutics and Clinical Risk... 2015Vasopressor agents are often prescribed in septic shock. However, their effects remain controversial. We conducted a systematic review and Bayesian network meta-analysis...
OBJECTIVE
Vasopressor agents are often prescribed in septic shock. However, their effects remain controversial. We conducted a systematic review and Bayesian network meta-analysis to compare the effects among different types of vasopressor agents.
DATA SOURCES
We searched for relevant studies in PubMed, Embase, and the Cochrane Library databases from database inception until December 2014.
STUDY SELECTION
Randomized controlled trials in adults with septic shock that evaluated different vasopressor agents were selected.
DATA EXTRACTION
Two authors independently selected studies and extracted data on study characteristics, methods, and outcomes.
DATA SYNTHESIS
Twenty-one trials (n=3,819) met inclusion criteria, which compared eleven vasopressor agents or vasopressor combinations (norepinephrine [NE], dopamine [DA], vasopressin [VP], epinephrine [EN], terlipressin [TP], phenylephrine [PE], TP+NE, TP + dobutamine [DB], NE+DB, NE+EN, and NE + dopexamine [DX]). Except for the superiority of NE over DA, the mortality of patients treated with any vasopressor agent or vasopressor combination was not significantly different. Compared to DA, NE was found to be associated with decreased cardiac adverse events, heart rate (standardized mean difference [SMD]: -2.10; 95% confidence interval [CI]: -3.95, -0.25; P=0.03), and cardiac index (SMD: -0.73; 95% CI: -1.14, -0.03; P=0.004) and increased systemic vascular resistance index (SVRI) (SMD: 1.03; 95% CI: 0.61, 1.45; P<0.0001). This Bayesian meta-analysis revealed a possible rank of probability of mortality among the eleven vasopressor agents or vasopressor combinations; from lowest to highest, they are NE+DB, EN, TP, NE+EN, TP+NE, VP, TP+DB, NE, PE, NE+DX, and DA.
CONCLUSION
In terms of survival, NE may be superior to DA. Otherwise, there is insufficient evidence to suggest that any other vasopressor agent or vasopressor combination is superior to another. When compared to DA, NE is associated with decreased heart rate, cardiac index, and cardiovascular adverse events, as well as increased SVRI. The effects of vasopressor agents or vasopressor combinations on mortality in patients with septic shock require further investigation.
PubMed: 26203253
DOI: 10.2147/TCRM.S80060 -
The Cochrane Database of Systematic... Mar 2015Children with congenital heart disease often undergo heart surgery at a young age. They are at risk for postoperative low cardiac output syndrome (LCOS) or death.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Children with congenital heart disease often undergo heart surgery at a young age. They are at risk for postoperative low cardiac output syndrome (LCOS) or death. Milrinone may be used to provide inotropic and vasodilatory support during the immediate postoperative period.
OBJECTIVES
This review examines the effectiveness of prophylactic postoperative use of milrinone to prevent LCOS or death in children having undergone surgery for congenital heart disease.
SEARCH METHODS
Electronic and manual literature searches were performed to identify randomised controlled trials. We searched CENTRAL, MEDLINE, EMBASE and Web of Science in February 2014 and conducted a top-up search in September 2014 as well as clinical trial registries and reference lists of published studies. We did not apply any language restrictions.
SELECTION CRITERIA
Only randomised controlled trials were selected for analysis. We considered studies with newborn infants, infants, toddlers, and children up to 12 years of age.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data according to a pre-defined protocol. We obtained additional information from all study authors.
MAIN RESULTS
Three of the five included studies compared milrinone versus levosimendan, one study compared milrinone with placebo, and one compared milrinone verus dobutamine, with 101, 242, and 50 participants, respectively. Three trials were at low risk of bias while two were at higher risk of bias. The number and definitions of outcomes were non-uniform as well. In one study comparing two doses of milrinone and placebo, there was some evidence in an overall comparison of milrinone versus placebo that milrinone lowered risk for LCOS (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.28 to 0.96; 227 participants). The results from two small studies do not provide enough information to determine whether milrinone increases the risk of LCOS when compared to levosimendan (RR 1.22, 95% CI 0.32 to 4.65; 59 participants). Mortality rates in the studies were low, and there was insufficient evidence to draw conclusions on the effect of milrinone compared to placebo or levosimendan or dobutamine regarding mortality, the duration of intensive care stay, hospital stay, mechanical ventilation, or maximum inotrope score (where available). Numbers of patients requiring mechanical cardiac support were also low and did not allow a comparison between studies, and none of the participants of any study received a heart transplantation up to the end of the respective follow-up period. Time to death within three months was not reported in any of the included studies. A number of adverse events was examined, but differences between the treatment groups could not be proven for hypotension, intraventricular haemorrhage, hypokalaemia, bronchospasm, elevated serum levels of liver enzymes, or a reduced left ventricular ejection fraction < 50% or reduced left ventricular fraction of shortening < 28%. Our analysis did not prove an increased risk of arrhythmias in patients treated prophylactically with milrinone compared with placebo (RR 3.59, 95% CI 0.83 to 15.42; 238 participants), a decreased risk of pleural effusions (RR 1.78, 95% CI 0.92 to 3.42; 231 participants), or a difference in risk of thrombocytopenia on milrinone compared with placebo (RR 0.86, 95% CI 0.39 to 1.88; 238 participants). Comparisons of milrinone with levosimendan or with dobutamine, respectively, did not clarify the risk of arrhythmia and were not possible for pleural effusions or thrombocytopenia.
AUTHORS' CONCLUSIONS
There is insufficient evidence of the effectiveness of prophylactic milrinone in preventing death or low cardiac output syndrome in children undergoing surgery for congenital heart disease, compared to placebo. So far, no differences have been shown between milrinone and other inodilators, such as levosimendan or dobutamine, in the immediate postoperative period, in reducing the risk of LCOS or death. The existing data on the prophylactic use of milrinone has to be viewed cautiously due to the small number of small trials and their risk of bias.
Topics: Cardiac Output, Low; Cardiotonic Agents; Dobutamine; Heart Defects, Congenital; Humans; Hydrazones; Infant; Infant, Newborn; Milrinone; Postoperative Complications; Pyridazines; Randomized Controlled Trials as Topic; Simendan; Syndrome; Time Factors
PubMed: 25806562
DOI: 10.1002/14651858.CD009515.pub2 -
European Journal of Heart Failure Dec 2014Cardiac function should be assessed during stress in patients with suspected heart failure with preserved ejection fraction (HFPEF), but it is unclear how to define... (Review)
Review
AIMS
Cardiac function should be assessed during stress in patients with suspected heart failure with preserved ejection fraction (HFPEF), but it is unclear how to define impaired diastolic reserve.
METHODS AND RESULTS
We conducted a systematic review to identify which pathophysiological changes serve as appropriate targets for diagnostic imaging. We identified 38 studies of 1111 patients with HFPEF (mean age 65 years), 744 control patients without HFPEF, and 458 healthy subjects. Qualifying EF was >45-55%; diastolic dysfunction at rest was a required criterion in 45% of studies. The initial workload during bicycle exercise (25 studies) varied from 12.5 to 30 W (mean 23.1 ± 4.6), with increments of 10-25 W (mean 19.9 ± 6) and stage duration 1-5 min (mean 2.5 ± 1); targets were submaximal (n = 8) or maximal (n = 17). Other protocols used treadmill exercise, handgrip, dobutamine, lower body negative pressure, nitroprusside, fluid challenge, leg raising, or atrial pacing. Reproducibility of echocardiographic variables during stress and validation against independent reference criteria were assessed in few studies. Change in E/e' was the most frequent measurement, but there is insufficient evidence to establish this or other tests for routine use when evaluating patients with HFPEF.
CONCLUSIONS
To meet the clinical requirements of performing stress testing in elderly subjects, we propose a ramped exercise protocol on a semi-supine bicycle, starting at 15 W, with increments of 5 W/min to a submaximal target (heart rate 100-110 b.p.m., or symptoms). Measurements during submaximal and recovery stages should include changes from baseline in LV long-axis function and indirect echocardiographic indices of LV diastolic pressure.
Topics: Aged; Aged, 80 and over; Clinical Protocols; Diastole; Exercise Test; Heart Failure; Humans; Stroke Volume; Ultrasonography; Ventricular Function, Left
PubMed: 25393338
DOI: 10.1002/ejhf.184 -
International Journal of Cardiology.... Sep 2014
PubMed: 29450191
DOI: 10.1016/j.ijchv.2014.07.005 -
PloS One 2014Although dobutamine is widely used in neonatal clinical practice, the evidence for its use in this specific population is not clear. We conducted a systematic review of... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Although dobutamine is widely used in neonatal clinical practice, the evidence for its use in this specific population is not clear. We conducted a systematic review of the use of dobutamine in juvenile animals to determine whether the evidence from juvenile animal experiments with dobutamine supported the design of clinical trials in neonatal/paediatric population.
METHODS
Studies were identified by searching MEDLINE (1946-2012) and EMBASE (1974-2012). Articles retrieved were independently reviewed by three authors and only those concerning efficacy and safety of the drug in juvenile animals were included. Only original articles published in English and Spanish were included.
RESULTS
Following our literature search, 265 articles were retrieved and 24 studies were included in the review: 17 focused on neonatal models and 7 on young animal models. Although the aims and design of these studies, as well as the doses and ages analysed, were quite heterogeneous, the majority of authors agree that dobutamine infusion improves cardiac output in a dose dependent manner. Moreover, the cardiovascular effects of dobutamine are influenced by postnatal age, as well as by the dose used and the duration of the therapy. There is inadequate information about the effects of dobutamine on cerebral perfusion to draw conclusions.
CONCLUSION
There is enough preclinical evidence to ensure that dobutamine improves cardiac output, however to better understand its effects in peripheral organs, such as the brain, more specific and well designed studies are required to provide additional data to support the design of clinical trials in a paediatric population.
Topics: Adrenergic beta-1 Receptor Agonists; Age Factors; Animals; Animals, Newborn; Cardiotonic Agents; Cardiovascular System; Dobutamine; Drug Evaluation, Preclinical; Humans; Models, Animal
PubMed: 24755688
DOI: 10.1371/journal.pone.0095644 -
Journal of the American College of... Aug 2013This study sought to perform a systematic review and meta-analysis to understand the role of stress cardiac magnetic resonance imaging (CMR) in assessing cardiovascular... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
This study sought to perform a systematic review and meta-analysis to understand the role of stress cardiac magnetic resonance imaging (CMR) in assessing cardiovascular prognosis in patients with known or suspected coronary artery disease (CAD).
BACKGROUND
Although stress CMR is excellent for the diagnosis of obstructive CAD, the prognostic value of stress CMR has been less well described.
METHODS
PubMed, Cochrane CENTRAL, and metaRegister of Controlled Trials were searched for stress CMR studies with >6 months of prognostic data. Primary endpoints were cardiovascular death, myocardial infarction (MI), and a composite outcome of cardiovascular death or MI during follow-up. Summary effect estimates were generated with random-effects modeling, and annualized event rates were assessed.
RESULTS
Nineteen studies (14 vasodilator, 4 dobutamine, and 1 that used both) involved a total of 11,636 patients with a mean follow-up of 32 months. Patients had a mean age of 63 ± 12 years, 63% were male, and 26% had previous MI; mean left ventricular ejection fraction was 61 ± 12%; and late gadolinium enhancement was present in 29% and ischemia in 32%. Patients with ischemia had a higher incidence of MI (odds ratio [OR]: 7.7; p < 0.0001), cardiovascular death (OR: 7.0; p < 0.0001), and the combined endpoint (OR: 6.5; p < 0.0001) compared with those with a negative study. The combined outcome annualized events rates were 4.9% for a positive versus 0.8% for a negative stress CMR (p < 0.0001), 2.8% versus 0.3% for cardiovascular death (p < 0.0001), and 2.6% versus 0.4% for MI (p < 0.0005). The presence of late gadolinium enhancement was also significantly associated with a worse prognosis.
CONCLUSIONS
A negative stress CMR study is associated with very low risk of cardiovascular death and MI. Stress CMR has excellent prognostic characteristics and may help guide risk stratification of patients with known or suspected CAD.
Topics: Aged; Coronary Artery Disease; Female; Follow-Up Studies; Gadolinium; Humans; Image Enhancement; Magnetic Resonance Imaging; Male; Middle Aged; Myocardial Infarction; Prognosis; Risk Assessment
PubMed: 23727209
DOI: 10.1016/j.jacc.2013.03.080 -
JACC. Cardiovascular Imaging May 2012The purpose of this study was to compare the diagnostic accuracy of cardiac magnetic resonance (CMR) assessing myocardial viability in patients with chronic left... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
The purpose of this study was to compare the diagnostic accuracy of cardiac magnetic resonance (CMR) assessing myocardial viability in patients with chronic left ventricular (LV) dysfunction due to coronary artery disease using 3 techniques: 1) end-diastolic wall thickness (EDWT); 2) low-dose dobutamine (LDD); and 3) contrast delayed enhancement (DE).
BACKGROUND
CMR has been proposed to assess myocardial viability over the past decade. However, the best CMR strategy to evaluate patients being contemplated for revascularization has not yet been determined. Some centers advocate DE CMR due to its high sensitivity to identify scar, whereas others favor the use of LDD CMR for its ability to identify contractile reserve.
METHODS
A systematic review of MEDLINE, Cochrane, and Embase for all the prospective trials assessing myocardial viability in subjects with chronic LV dysfunction using CMR was performed using a standard approach for meta-analysis for diagnostic tests and a bivariate analysis of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
RESULTS
A total of 24 studies of CMR evaluating myocardial viability with 698 patients fulfilled the inclusion criteria. Eleven studies used DE, 9 studies used LDD, and 4 studies used EDWT. Our meta-analysis indicates that among CMR methods, DE CMR provides the highest sensitivity as well as the highest NPV (95% and 90%, respectively) for predicting improved segmental LV contractile function after revascularization, followed by EDWT CMR, whereas LDD CMR demonstrated the lowest sensitivity/NPV among all modalities. On the other hand, LDD CMR offered the highest specificity and PPV (91% and 93%, respectively), followed by DE CMR, whereas EDWT showed the lowest of these parameters.
CONCLUSIONS
DE CMR provides the highest sensitivity and NPV, whereas LDD CMR provides the best specificity and PPV. In light of these findings, integrating these 2 methods should provide increased accuracy in evaluating patients with chronic LV dysfunction being considered for revascularization.
Topics: Aged; Cardiotonic Agents; Chronic Disease; Clinical Trials as Topic; Contrast Media; Coronary Disease; Dobutamine; Evidence-Based Medicine; Female; Heart Ventricles; Humans; Logistic Models; Magnetic Resonance Imaging; Male; Middle Aged; Myocardial Contraction; Myocardial Stunning; Myocardium; Predictive Value of Tests; Prognosis; Prospective Studies; Sensitivity and Specificity; Tissue Survival; Ventricular Dysfunction, Left; Ventricular Function, Left
PubMed: 22595157
DOI: 10.1016/j.jcmg.2012.02.009 -
The Cochrane Database of Systematic... Dec 2011Patients with chronic kidney disease (CKD) are at increased risk of coronary artery disease (CAD) and adverse cardiac events. Screening for CAD is therefore an important... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Patients with chronic kidney disease (CKD) are at increased risk of coronary artery disease (CAD) and adverse cardiac events. Screening for CAD is therefore an important part of preoperative evaluation for kidney transplant candidates. There is significant interest in the role of non-invasive cardiac investigations and their ability to identify patients at high risk of CAD.
OBJECTIVES
We investigated the accuracy of non-invasive cardiac screening tests compared with coronary angiography to detect CAD in patients who are potential kidney transplant recipients.
SEARCH METHODS
MEDLINE and EMBASE searches (inception to November 2010) were performed to identify studies that assessed the diagnostic accuracy of non-invasive screening tests, using coronary angiography as the reference standard. We also conducted citation tracking via Web of Science and handsearched reference lists of identified primary studies and review articles.
SELECTION CRITERIA
We included in this review all diagnostic cross sectional, cohort and randomised studies of test accuracy that compared the results of any cardiac test with coronary angiography (the reference standard) relating to patients considered as potential candidates for kidney transplantation or kidney-pancreas transplantation at the time diagnostic tests were performed.
DATA COLLECTION AND ANALYSIS
We used a hierarchical modelling strategy to produce summary receiver operating characteristic (SROC) curves, and pooled estimates of sensitivity and specificity. Sensitivity analyses to determine test accuracy were performed if only studies that had full verification or applied a threshold of ≥ 70% stenosis on coronary angiography for the diagnosis of significant CAD were included.
MAIN RESULTS
The following screening investigations included in the meta-analysis were: dobutamine stress echocardiography (DSE) (13 studies), myocardial perfusion scintigraphy (MPS) (nine studies), echocardiography (three studies), exercise stress electrocardiography (two studies), resting electrocardiography (three studies), and one study each of electron beam computed tomography (EBCT), exercise ventriculography, carotid intimal media thickness (CIMT) and digital subtraction fluorography (DSF). Sufficient studies were present to allow hierarchical summary receiver operating characteristic (HSROC) analysis for DSE and MPS. When including all available studies, both DSE and MPS had moderate sensitivity and specificity in detecting coronary artery stenosis in patients who are kidney transplant candidates [DSE (13 studies) - pooled sensitivity 0.79 (95% CI 0.67 to 0.88), pooled specificity 0.89 (95% CI 0.81 to 0.94); MPS (nine studies) - pooled sensitivity 0.74 (95% CI 0.54 to 0.87), pooled specificity 0.70 (95% CI 0.51 to 0.84)]. When limiting to studies which defined coronary artery stenosis using a reference threshold of ≥ 70% stenosis on coronary angiography, there was little change in these pooled estimates of accuracy [DSE (9 studies) - pooled sensitivity 0.76 (95% CI 0.60 to 0.87), specificity 0.88 (95% CI 0.78 to 0.94); MPS (7 studies) - pooled sensitivity 0.67 (95% CI 0.48 to 0.82), pooled specificity 0.77 (95% CI 0.61 to 0.88)]. There was evidence that DSE had improved accuracy over MPS (P = 0.02) when all studies were included in the analysis, but this was not significant when we excluded studies which did not avoid partial verification or use a reference standard threshold of ≥70% stenosis (P = 0.09).
AUTHORS' CONCLUSIONS
DSE may perform better than MPS but additional studies directly comparing these cardiac screening tests are needed. Absence of significant CAD may not necessarily correlate with cardiac-event free survival following transplantation. Further research should focus on assessing the ability of functional tests to predict postoperative outcome.
Topics: Coronary Angiography; Coronary Artery Disease; Heart Function Tests; Humans; Kidney Failure, Chronic; Kidney Transplantation; Pancreas Transplantation; Reference Standards
PubMed: 22161434
DOI: 10.1002/14651858.CD008691.pub2 -
Critical Care (London, England) 2010Pulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a... (Review)
Review
INTRODUCTION
Pulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and reduction of RV afterload by lowering pulmonary vascular resistance (PVR). We therefore provide a detailed update on the management of PH and RV failure in adult critical care.
METHODS
A systematic review was performed, based on a search of the literature from 1980 to 2010, by using prespecified search terms. Relevant studies were subjected to analysis based on the GRADE method.
RESULTS
Clinical studies of intensive care management of pulmonary vascular dysfunction were identified, describing volume therapy, vasopressors, sympathetic inotropes, inodilators, levosimendan, pulmonary vasodilators, and mechanical devices. The following GRADE recommendations (evidence level) are made in patients with pulmonary vascular dysfunction: 1) A weak recommendation (very-low-quality evidence) is made that close monitoring of the RV is advised as volume loading may worsen RV performance; 2) A weak recommendation (low-quality evidence) is made that low-dose norepinephrine is an effective pressor in these patients; and that 3) low-dose vasopressin may be useful to manage patients with resistant vasodilatory shock. 4) A weak recommendation (low-moderate quality evidence) is made that low-dose dobutamine improves RV function in pulmonary vascular dysfunction. 5) A strong recommendation (moderate-quality evidence) is made that phosphodiesterase type III inhibitors reduce PVR and improve RV function, although hypotension is frequent. 6) A weak recommendation (low-quality evidence) is made that levosimendan may be useful for short-term improvements in RV performance. 7) A strong recommendation (moderate-quality evidence) is made that pulmonary vasodilators reduce PVR and improve RV function, notably in pulmonary vascular dysfunction after cardiac surgery, and that the side-effect profile is reduced by using inhaled rather than systemic agents. 8) A weak recommendation (very-low-quality evidence) is made that mechanical therapies may be useful rescue therapies in some settings of pulmonary vascular dysfunction awaiting definitive therapy.
CONCLUSIONS
This systematic review highlights that although some recommendations can be made to guide the critical care management of pulmonary vascular and right ventricular dysfunction, within the limitations of this review and the GRADE methodology, the quality of the evidence base is generally low, and further high-quality research is needed.
Topics: Adult; Antihypertensive Agents; Critical Care; Disease Management; Humans; Hypertension, Pulmonary; Vascular Resistance; Vasoconstrictor Agents; Ventricular Dysfunction, Right
PubMed: 20858239
DOI: 10.1186/cc9264