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Annals of Medicine and Surgery (2012) Jun 2023There are limited data available on outcomes and pathophysiology behind ST-segment elevation myocardial infarction (STEMI) in populations without standard modifiable...
Differences in treatment and outcomes among patients with ST-segment elevation myocardial infarction with and without standard modifiable risk factors: a systematic review and meta-analysis.
UNLABELLED
There are limited data available on outcomes and pathophysiology behind ST-segment elevation myocardial infarction (STEMI) in populations without standard modifiable risk factors (SMuRFs). The authors carried out this meta-analysis to understand the differences in treatment and outcomes of STEMI patients with and without SMuRFs.
METHODS
A systematic database search was performed for relevant studies. Studies reporting desired outcomes among STEMI patients with and without SMuRFs were selected based on predefined criteria in the study protocol (PROSPERO: CRD42022341389). Two reviewers independently screened titles and abstracts using Covidence. Full texts of the selected studies were independently reviewed to confirm eligibility. Data were extracted from all eligible studies via a full-text review of the primary article for qualitative and quantitative analysis. In-hospital mortality following the first episode of STEMI was the primary outcome, with major adverse cardiovascular events (MACE), repeat myocardial infarction (MI), cardiogenic shock, heart failure, and stroke as secondary outcomes of interest. Odds ratio (OR) with a 95% CI was used to estimate the effect.
RESULTS
A total of 2135 studies were identified from database search, six studies with 521 150 patients with the first STEMI episode were included in the analysis. The authors found higher in-hospital mortality (OR: 1.43; CI: 1.40-1.47) and cardiogenic shock (OR: 1.59; 95% CI: 1.55-1.63) in the SMuRF-less group with no differences in MACE, recurrent MI, major bleeding, heart failure, and stroke. There were lower prescriptions of statin (OR: 0.62; CI: 0.42-0.91) and Angiotensin converting enzyme inhibitor /Angiotensin II receptor blocker (OR: 0.49; CI: 0.28-0.87) at discharge in SMuRF-less patients. There was no difference in procedures like coronary artery bypass graft, percutaneous coronary intervention, and thrombolysis.
CONCLUSION
In the SMuRF-less STEMI patients, higher in-hospital mortality and treatment discrepancies were noted at discharge.
PubMed: 37363488
DOI: 10.1097/MS9.0000000000000738 -
Critical Care Explorations Jun 2023Studies evaluating inhaled prostacyclins for the management of acute respiratory distress syndrome (ARDS) have produced inconsistent results regarding their effect on... (Review)
Review
UNLABELLED
Studies evaluating inhaled prostacyclins for the management of acute respiratory distress syndrome (ARDS) have produced inconsistent results regarding their effect on oxygenation. The purpose of this systematic review and meta-analysis was to evaluate the change in the Pao/Fio ratio after administration of an inhaled prostacyclin in patients with ARDS.
DATA SOURCES
We searched Ovid Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane, Scopus, and Web of Science.
STUDY SELECTION
We included abstracts and trials evaluating administration of inhaled prostacyclins in patients with ARDS.
DATA EXTRACTION
Change in the Pao/Fio ratio, Pao, and mean pulmonary artery pressure (mPAP) were extracted from included studies. Evidence certainty and risk of bias were evaluated using Grading of Recommendations Assessment, Development, and Evaluation and the Cochrane Risk of Bias tool.
DATA SYNTHESIS
We included 23 studies (1,658 patients) from 6,339 abstracts identified by our search strategy. The use of inhaled prostacyclins improved oxygenation by increasing the Pao/Fio ratio from baseline (mean difference [MD], 40.35; 95% CI, 26.14-54.56; < 0.00001; = 95%; very low quality evidence). Of the eight studies to evaluate change in Pao, inhaled prostacyclins also increased Pao from baseline (MD, 12.68; 95% CI, 2.89-22.48 mm Hg; = 0.01; = 96%; very low quality evidence). Only three studies evaluated change in mPAP, but inhaled prostacyclins were found to improve mPAP from baseline (MD, -3.67; 95% CI, -5.04 to -2.31 mm Hg; < 0.00001; = 68%; very low quality evidence).
CONCLUSIONS
In patients with ARDS, use of inhaled prostacyclins improves oxygenation and reduces pulmonary artery pressures. Overall data are limited and there was high risk of bias and heterogeneity among included studies. Future studies evaluating inhaled prostacyclins for ARDS should evaluate their role in ARDS subphenotypes, including cardiopulmonary ARDS.
PubMed: 37303944
DOI: 10.1097/CCE.0000000000000931 -
Cureus Apr 2023Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy,... (Review)
Review
Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy, including liberal fluid therapy (LFT), restrictive fluid therapy (RFT) and goal-directed fluid therapy (GDT), without a clear consensus as to which is better. We aimed to find out which is the more effective fluid therapy option in adult surgical patients undergoing non-vascular abdominal surgery in the perioperative period. This study is a systematic review and network meta-analysis (NMA) with node-splitting analysis of inconsistency, sensitivity analysis and meta-regression. We conducted a literature search of Pubmed, Cochrane Library, EMBASE, Google Scholar and Web of Science. Only studies comparing restrictive, liberal and goal-directed fluid therapy during the perioperative phase in major non-cardiac surgery in adult patients will be included. Trials on paediatric patients, obstetric patients and cardiac surgery were excluded. Trials that focused on goal-directed therapy monitoring with pulmonary artery catheters and venous oxygen saturation (SvO2), as well as those examining purely biochemical and laboratory end points, were excluded. A total of 102 randomised controlled trials (RCTs) and 78 studies (12,100 patients) were included. NMA concluded that goal-directed fluid therapy utilising FloTrac was the most effective intervention in reducing the length of stay (LOS) (surface under cumulative ranking curve (SUCRA) = 91%, odds ratio (OR) = -2.4, 95% credible intervals (CrI) = -3.9 to -0.85) and wound complications (SUCRA = 86%, OR = 0.41, 95% CrI = 0.24 to 0.69). Goal-directed fluid therapy utilising pulse pressure variation was the most effective in reducing the complication rate (SUCRA = 80%, OR = 0.25, 95% CrI = 0.047 to 1.2), renal complications (SUCRA = 93%, OR = 0.23, 95% CrI = 0.045 to 1.0), respiratory complications (SUCRA = 74%, OR = 0.42, 95% CrI = 0.053 to 3.6) and cardiac complications (SUCRA = 97%, OR = 0.067, 95% CrI = 0.0058 to 0.57). Liberal fluid therapy was the most effective in reducing the mortality rate (SUCRA = 81%, OR = 0.40, 95% CrI = 0.12 to 1.5). Goal-directed therapy utilising oesophageal Doppler was the most effective in reducing anastomotic leak (SUCRA = 79%, OR = 0.45, 95% CrI = 0.12 to 1.5). There was no publication bias, but moderate to substantial heterogeneity was found in all networks. In preventing different complications, except mortality, goal-directed fluid therapy was consistently more highly ranked and effective than standard (SFT), liberal or restricted fluid therapy. The evidence grade was low quality to very low quality for all the results, except those for wound complications and anastomotic leak.
PubMed: 37261162
DOI: 10.7759/cureus.38238 -
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 -
Interdisciplinary Cardiovascular and... May 2023Right heart failure (RHF) is a major complication following left ventricular assist device (LVAD) implantation. Pulmonary artery pulsatility index (PAPi) has been...
OBJECTIVES
Right heart failure (RHF) is a major complication following left ventricular assist device (LVAD) implantation. Pulmonary artery pulsatility index (PAPi) has been evaluated as a haemodynamic marker for RHF, but PAPi is dependent on pulmonary vascular resistance (PVR). We conducted a systematic review to assess the relationship between PAPi and RHF and death in patients undergoing LVAD implantation and examined the relationship between PAPi cut-off and PVR.
METHODS
We searched PubMed, EMBASE, CENTRAL and manually screened retrieved references to identify all clinical studies reporting PAPi in adult patients with a durable LVAD. Eligibility criteria were prespecified and 2 reviewers independently screened and extracted data; the Newcastle-Ottawa Scale was used to assess quality of non-randomized studies. This study was prospectively registered on PROSPERO (CRD42021259009).
RESULTS
From 283 unique records, we identified 16 studies reporting haemodynamic assessment in 20 634 adult patients with an implanted durable LVAD. Only 2 studies reported on mortality and in both, a lower PAPi was significantly associated with death. Fifteen studies reported RHF data and, in 10 studies, a lower PAPi was significantly associated with RHF. Six studies reported on PAPi cut-offs ranging from 0.88 to 3.3; and the cut-offs were directly related to PVR (r = 0.6613, P = 0.019).
CONCLUSIONS
Lower PAPi was associated with RHF and death following LVAD implantation, but a single PAPi cut-off cannot be defined, as it is dependent on PVR.
PubMed: 37171900
DOI: 10.1093/icvts/ivad068 -
EClinicalMedicine May 2023Isolated pulmonary embolism (PE) appears to be associated with a specific clinical profile and sequelae compared to deep vein thrombosis (DVT)-associated PE. The...
BACKGROUND
Isolated pulmonary embolism (PE) appears to be associated with a specific clinical profile and sequelae compared to deep vein thrombosis (DVT)-associated PE. The objective of this study was to identify clinical characteristics that discriminate both phenotypes, and to characterize their differences in clinical outcome.
METHODS
We performed a systematic review and meta-analysis of studies comparing PE phenotypes. A systematic search of the electronic databases PubMed and CENTRAL was conducted, from inception until January 27, 2023. Exclusion criteria were irrelevant content, inability to retrieve the article, language other than English or German, the article comprising a review or case study/series, and inappropriate study design. Data on risk factors, clinical characteristics and clinical endpoints were pooled using random-effects meta-analyses.
FINDINGS
Fifty studies with 435,768 PE patients were included. In low risk of bias studies, 30% [95% CI 19-42%, = 97%] of PE were isolated. The Factor V Leiden [OR: 0.47, 95% CI 0.37-0.58, = 0%] and prothrombin G20210A mutations [OR: 0.55, 95% CI 0.41-0.75, = 0%] were significantly less prevalent among patients with isolated PE. Female sex [OR: 1.30, 95% CI 1.17-1.45, = 79%], recent invasive surgery [OR: 1.31, 95% CI 1.23-1.41, = 65%], a history of myocardial infarction [OR: 2.07, 95% CI 1.85-2.32, = 0%], left-sided heart failure [OR: 1.70, 95% CI 1.37-2.10, = 76%], peripheral artery disease [OR: 1.36, 95% CI 1.31-1.42, = 0%] and diabetes mellitus [OR: 1.23, 95% CI 1.21-1.25, = 0%] were significantly more frequently represented among isolated PE patients. In a synthesis of clinical outcome data, the risk of recurrent VTE in isolated PE was half that of DVT-associated PE [RR: 0.55, 95% CI 0.44-0.69, = 0%], while the risk of arterial thrombosis was nearly 3-fold higher [RR: 2.93, 95% CI 1.43-6.02, = 0%].
INTERPRETATION
Our findings suggest that isolated PE appears to be a specific entity that may signal a long-term risk of arterial thrombosis. Randomised controlled trials are necessary to establish whether alternative treatment regimens are beneficial for this patient subgroup.
FUNDING
None.
PubMed: 37152363
DOI: 10.1016/j.eclinm.2023.101973 -
Medical Journal of the Islamic Republic... 2023Heart Failure (HF) imposes a relevant burden and a considerable health concern, with high prevalence and mortality rates. This study was conducted to assess the... (Review)
Review
BACKGROUND
Heart Failure (HF) imposes a relevant burden and a considerable health concern, with high prevalence and mortality rates. This study was conducted to assess the cost-effectiveness of remote cardiac monitoring with the CardioMEMS Heart Failure System.
METHODS
In the present systematic review, several scholarly databases were searched and updated from inception up to September 20, 2022. The objective of the present review was formulated according to the patient/population, intervention, comparison and outcomes format. Mortality rate, hospitalization rate, quality-adjusted life year (QALY), total costs, and the incremental cost-effectiveness ratio regarding the use of the CardioMEMS System were the key outcomes of the present study. The quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS) checklist.
RESULTS
Finally, 5 articles were retained and analyzed in the present systematic review. All studies employed the Markov and decision tree models. Results show that the CardioMEMS system reduced mortality and hospitalization rate and created a higher QALY. In all selected countries the CardioMEMS method is a more expensive method than the standard of care (SoC), with the highest cost in the United States (US) ($201,437) and the lowest cost in the United Kingdom ($25,963), respectively. the highest willingness to pay in the US and the lowest in Italy ($100,000 and $33,000 per QALY), respectively. Results showed that the most cost per QALY for the CardioMEMS system was in the US and the lowest was in the Netherlands ($46,622 and $26,615 per QALY), respectively.
CONCLUSION
In all selected countries, CardioMEMS is a cost-effective method for monitoring and managing pulmonary artery pressures in HF patients. Strategies such as CardioMEMS, which decrease the rate of hospitalization, are likely to be only more cost-effective in the future.
PubMed: 37123330
DOI: 10.47176/mjiri.37.16 -
JACC. Cardiovascular Interventions Apr 2023Balloon pulmonary angioplasty (BPA) was introduced as a treatment modality for patients with inoperable, medically refractory chronic thromboembolic pulmonary...
BACKGROUND
Balloon pulmonary angioplasty (BPA) was introduced as a treatment modality for patients with inoperable, medically refractory chronic thromboembolic pulmonary hypertension decades ago; however, reports of high rates of pulmonary vascular injury have led to considerable refinement in procedural technique.
OBJECTIVES
The authors sought to better understand the evolution of BPA procedure-related complications over time.
METHODS
The authors conducted a systematic review of original articles published by pulmonary hypertension centers globally and performed a pooled cohort analysis of procedure-related outcomes with BPA.
RESULTS
This systematic review identified 26 published articles from 18 countries worldwide from 2013 to 2022. A total of 1,714 patients underwent 7,561 total BPA procedures with an average follow up of 7.3 months. From the first period (2013-2017) to the second period (2018-2022), the cumulative incidence of hemoptysis/vascular injury decreased from 14.1% (474/3,351) to 7.7% (233/3,029) (P < 0.01); lung injury/reperfusion edema decreased from 11.3% (377/3,351) to 1.4% (57/3,943) (P < 0.01); invasive mechanical ventilation decreased from 0.7% (23/3,195) to 0.1% (4/3,062) (P < 0.01); and mortality decreased from 2.0% (13/636) to 0.8% (8/1,071) (P < 0.01).
CONCLUSIONS
Procedure-related complications with BPA, including hemoptysis/vascular injury, lung injury/reperfusion edema, mechanical ventilation, and death, were less common in the second period (2018-2022), compared with first period (2013-2017), likely from refinement in patient and lesion selection and procedural technique over time.
Topics: Humans; Pulmonary Artery; Hypertension, Pulmonary; Pulmonary Embolism; Hemoptysis; Lung Injury; Vascular System Injuries; Treatment Outcome; Angioplasty, Balloon; Pulmonary Edema; Edema; Chronic Disease
PubMed: 37100561
DOI: 10.1016/j.jcin.2023.01.361 -
Cureus Mar 2023This study aims to evaluate the role of preoperative vitamin D supplementation before coronary artery bypass grafting (CABG) surgery in preventing postoperative atrial... (Review)
Review
The Role of Vitamin D Supplementation Before Coronary Artery Bypass Grafting in Preventing Postoperative Atrial Fibrillation in Patients With Vitamin D Deficiency or Insufficiency: A Systematic Review and Meta-Analysis.
This study aims to evaluate the role of preoperative vitamin D supplementation before coronary artery bypass grafting (CABG) surgery in preventing postoperative atrial fibrillation (POAF) in vitamin D deficient or insufficient patients. Three randomized controlled trials (RCTs) comprising 448 subjects were selected after a detailed search was conducted on PubMed, Cochrane CENTRAL, Scopus, and Embase in December 2022. Analysis was run using RevMan (version 5.4.1; Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). The analysis collected risk ratio (RR) and 95% confidence interval (CI) data from the relevant studies, which were then pooled using a random effects model. A significance level of less than 0.05 (p<0.05) was considered significant. Our analysis showed that compared with the standard of care, preoperative vitamin D supplementation in vitamin D deficient and insufficient patients effectively reduced POAF after CABG surgery (RR=0.6, 95% CI=0.4-0.9, P=0.01). There was no significant difference in the duration of hospitalization between the vitamin D supplementation group compared with the control following CABG (mean difference -0.85, 95% CI -2.13 to 0.43, P = 0.19). This meta-analysis shows that preoperative vitamin D supplementation in vitamin D deficient and insufficient patients undergoing CABG can reduce the rate of POAF. As POAF is associated with many complications, providing vitamin D supplementation to individuals with a vitamin D deficiency undergoing CABG can improve long-term cardiovascular outcomes following surgery.
PubMed: 37090368
DOI: 10.7759/cureus.36496 -
Journal of Thoracic Disease Mar 2023Cardiogenic shock is associated with significant morbidity and mortality. Invasive hemodynamic monitoring with pulmonary artery catheterization (PAC) can be useful in...
BACKGROUND
Cardiogenic shock is associated with significant morbidity and mortality. Invasive hemodynamic monitoring with pulmonary artery catheterization (PAC) can be useful in the assessment of changes in cardiac function and hemodynamic status; however, the benefits of PAC in the management of cardiogenic shock are not known well.
METHODS
We performed a systematic review and meta-analysis of observational studies and randomized controlled trials, comparing in-hospital mortality between PAC and non-PAC groups of cardiogenic shock patients with various underlying causes. Articles were obtained from MEDLINE, Embase, and Cochrane CENTRAL. We reviewed titles, abstracts, and full articles and evaluated the quality of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework. We used a random-effects model to compare studies in terms of in-hospital mortality findings.
RESULTS
We included twelve articles in our meta-analysis. Mortality among patients with cardiogenic shock was not significantly different between the PAC and the non-PAC groups [risk ratio (RR) 0.86, 95% confidence interval (CI): 0.73-1.02, I=100%, P<0.01]. Two studies investigating cardiogenic shock caused by acute decompensated heart failure determined lower in-hospital mortality in the PAC group than in the non-PAC group (RR 0.49, 95% CI: 0.28-0.87, I=45%, P=0.18). Six studies investigating cardiogenic shock of any cause determined lower in-hospital mortality in the PAC group than in the non-PAC group (RR 0.84, 95% CI: 0.72-0.97, I=99%, P<0.01). There was no significant difference in in-hospital mortality between the PAC and non-PAC groups of patients with cardiogenic shock secondary to acute coronary syndrome (RR 1.01, 95% CI: 0.81-1.25, I=99%, P<0.01).
CONCLUSIONS
Overall, our meta-analysis demonstrated no significant association between PAC monitoring and in-hospital mortality among patients managed for cardiogenic shock. The use of PAC in the management of cardiogenic shock caused by acute decompensated heart failure was associated with lower in-hospital mortality, but there was no association between PAC monitoring and in-hospital mortality among patients with cardiogenic shock caused by acute coronary syndrome.
PubMed: 37065575
DOI: 10.21037/jtd-22-1139