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Cureus Sep 2023Despite significant pharmacological advancements, hypertension management remains challenging, with varying quality of primary care. Digital tools and other... (Review)
Review
Despite significant pharmacological advancements, hypertension management remains challenging, with varying quality of primary care. Digital tools and other non-pharmacological interventions hold promise in addressing this challenge. Consequently, a thorough examination of these interventions is recommended. This meta-analysis focuses on clinician-oriented strategies aimed at improving hypertension management, to assess the most effective approaches for improving antihypertensive prescribing and blood pressure control for secondary prevention. This was done through a systematic review of randomized controlled trials published in PubMed and Embase since the beginning of 2010 that aimed to enhance antihypertensive medication prescription in primary care settings for hypertensive patients with secondary complications while reporting changes in blood pressure or target achievement. We screened 6305 records. Four studies met the inclusion criteria, with reported interventions including physician education and the implementation of electronic decision support systems. All studies showed that the control group had a statistically significant lower systolic blood pressure, but the effect on diastolic blood pressure was not statistically significant. The overall mean difference was 2.12 mmHg (95% CI = 0.98; 3.26, P-value = 0.0003) for systolic blood pressure in favor of the control group and 1.22 mmHg (95% CI = -0.48; 3.26, P-value = 0.16) for diastolic blood pressure, which was not statistically significant. Despite considerable efforts to control hypertension, it remains a significant obstacle to optimal cardiovascular risk reduction. This review is also limited by a scarcity of studies.
PubMed: 37750065
DOI: 10.7759/cureus.45834 -
Vascular Health and Risk Management 2023Higher medication adherence reduces the risk of new cardiovascular events. However, there are individual and health system barriers that lead to lower adherence. The... (Review)
Review
BACKGROUND
Higher medication adherence reduces the risk of new cardiovascular events. However, there are individual and health system barriers that lead to lower adherence. The polypill has demonstrated benefits in cardiovascular morbidity and mortality mainly driven by an increase in adherence. We aim to evaluate the impact of the polypill on adherence to cardiovascular medication, its efficacy and safety in cardiovascular disease (CVD) prevention.
METHODS
A systematic review following PRISMA guidelines was conducted. Databases were searched from January 2003 to December 2022. We included randomized, pragmatic, or real-world clinical trials and observational studies. The primary outcome was medication adherence, secondary outcomes were efficacy in cardiovascular disease in primary and secondary prevention and safety.
RESULTS
From the 490 publications screened, 13 met the inclusion criteria and were incorporated into a comparative table Of those included, 70% were randomized controlled trials (RCTs) and 53.8% focused on secondary prevention. Most of the studies received a high and moderate quality rating. Self-report, pill counting and, the Morisky scale were the most frequent methods to evaluate adherence (84.6%). Compared with standard medication, the polypill improved overall medication adherence by 13%, with percentages ranging from 7.6% to 34.9%. Moreover, a potential benefit was also observed in reducing Major Adverse Cardiovascular Events (MACE), particularly in secondary prevention studies, with hazard ratios ranged between 0.43 to 0.76. Compared to standard care, the profile of side effects was similar.
CONCLUSION
The polypill is an effective, safe, and practical strategy to improve adherence in people at risk of CVD. Although there is a demonstrated benefit in reducing MACE, predominantly in secondary prevention, there are still gaps in its efficacy in primary prevention and reducing total mortality. Therefore, the importance of obtaining long-term results of the polypill effect and how this strategy can be implemented in real practice.
Topics: Humans; Cardiovascular Diseases; Secondary Prevention; Cardiovascular Agents; Databases, Factual; Medication Adherence
PubMed: 37719697
DOI: 10.2147/VHRM.S421024 -
Frontiers in Medicine 2023Pulmonary hypertension due to chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) is classified as group 3 pulmonary hypertension. Inhaled... (Review)
Review
BACKGROUND
Pulmonary hypertension due to chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) is classified as group 3 pulmonary hypertension. Inhaled treprostinil, a prostaglandin I analogue also known as prostacyclin, has recently been approved as a first drug for patients with pulmonary hypertension secondary to ILD. However, due to a lack of evidence, no therapies are currently approved for those with COPD-associated pulmonary hypertension. Thus, this systematic review aims to summarise the current evidence to assess the impact of inhaled prostaglandin I analogue use on the pulmonary hemodynamics, exercise function, lung function, and gas exchange in patients with pulmonary hypertension due to COPD.
METHODS
We systematically searched the electronic databases of Medline, Embase, Scopus and Cochrane from inception to 1 February 2023. Studies of adult patients with a confirmed diagnosis of COPD-associated pulmonary hypertension who received inhaled drugs targeting the prostacyclin pathway were included in the systematic review. Case reports, systematic reviews, conference abstracts with no full text, non-full-text articles, non-English manuscripts and book chapters were excluded from this systematic review. A risk-of-bias assessment was carried out for the studies included in this review, using two different Cochrane risk-of-bias tools for randomised and non-randomised clinical trials.
RESULTS
A total of four studies met our inclusion criteria and were included in this systematic review. The results of one prospective clinical trial showed an improvement in the pulmonary hemodynamics (e.g., cardiac index, cardiac output and mean pulmonary artery pressure) in response to inhaled prostacyclin use in patients with pulmonary hypertension secondary to COPD. However, the severity of dyspnoea, lung function, exercise capacity and gas exchange were not affected when inhaled prostacyclin was used for patients with COPD-related pulmonary hypertension.
CONCLUSION
This systematic review demonstrated that although inhaled prostacyclin does not seem to improve COPD-related outcomes (e.g., lung function and exercise capacity), short-term use of inhaled prostacyclin has the potential to reduce mean pulmonary artery pressure and pulmonary vascular resistance without impairing ventilation-perfusion mismatch. Further studies with larger sample sizes are warranted.
SYSTEMATIC REVIEW REGISTRATION
CRD42022372803, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=372803.
PubMed: 37706024
DOI: 10.3389/fmed.2023.1217156 -
Frontiers in Endocrinology 2023To investigate the effect of embryo stage at the time of transfer on obstetric and perinatal outcomes in programmed frozen-thawed embryo transfer (FET) versus natural... (Meta-Analysis)
Meta-Analysis
The influence of embryo stage on obstetric complications and perinatal outcomes following programmed compared to natural frozen-thawed embryo transfer cycles: a systematic review and meta-analysis.
OBJECTIVE
To investigate the effect of embryo stage at the time of transfer on obstetric and perinatal outcomes in programmed frozen-thawed embryo transfer (FET) versus natural FET cycles.
DESIGN
Systematic review and meta-analysis.
SETTING
Not applicable.
PATIENTS
Women with programmed frozen-thawed embryo transfer (FET) and natural FET.
INTERVENTIONS
The PubMed, MEDLINE, and EMBASE databases and the Cochrane Central Register of Controlled Trials (CCRT) were searched from 1983 to October 2022. Twenty-three observational studies were included.
PRIMARY OUTCOME MEASURE
The primary outcomes were hypertensive disorders of pregnancy (HDPs), gestational hypertension and preeclampsia (PE). The secondary outcomes were gestational diabetes mellitus (GDM), placenta previa, postpartum haemorrhage (PPH), placental abruption, preterm premature rupture of membranes (PPROM), large for gestational age (LGA), small for gestational age (SGA), macrosomia, and preterm delivery (PTD).
RESULTS
The risk of HDP (14 studies, odds ratio (OR) 2.17; 95% confidence interval (CI) 1.95-2.41; P<0.00001; I = 43%), gestational hypertension (11 studies, OR 1.38; 95% CI 1.15-1.66; P=0.0006; I = 19%), PE (12 studies, OR 2.09; 95% CI 1.88-2.32; P<0.00001; I = 0%), GDM (20 studies, OR 1.09; 95% CI 1.02-1.17; P=0.02; I = 8%), LGA (18 studies, OR 1.11; 95% CI 1.07-1.15; P<0.00001; I = 46%), macrosomia (12 studies, OR 1.15; 95% CI 1.07-1.24; P=0.0002; I = 31%), PTD (22 studies, OR 1.21; 95% CI 1.15-1.27; P<0.00001; I = 49%), placenta previa (17 studies, OR 1.2; 95% CI 1.02-1.41; P=0.03; I = 11%), PPROM (9 studies, OR 1.19; 95% CI 1.02-1.39; P=0.02; I = 40%), and PPH (12 studies, OR 2.27; 95% CI 2.02-2.55; P <0.00001; I = 55%) were increased in programmed FET cycles versus natural FET cycles with overall embryo transfer. Blastocyst transfer had a higher risk of HDP (6 studies, OR 2.48; 95% CI 2.12-2.91; P<0.00001; I = 39%), gestational hypertension (5 studies, OR 1.87; 95% CI 1.27-2.75; P=0.002; I = 25%), PE (6 studies, OR 2.23; 95% CI 1.93-2.56; P<0.00001; I = 0%), GDM (10 studies, OR 1.13; 95% CI 1.04-1.23; P=0.005; I = 39%), LGA (6 studies, OR 1.14; 95% CI 1.07-1.21; P<0.0001; I = 9%), macrosomia (4 studies, OR 1.15; 95% CI 1.05-1.26; P<0.002; I = 68%), PTD (9 studies, OR 1.43; 95% CI 1.31-1.57; P<0.00001; I = 22%), PPH (6 studies, OR 1.92; 95% CI 1.46-2.51; P<0.00001; I = 55%), and PPROM (4 studies, OR 1.45; 95% CI 1.14-1.83; P=0.002; I = 46%) in programmed FET cycles than in natural FET cycles. Cleavage-stage embryo transfers revealed no difference in HDPs (1 study, OR 0.81; 95% CI 0.32-2.02; P=0.65; I not applicable), gestational hypertension (2 studies, OR 0.85; 95% CI 0.48-1.51; P=0.59; I = 0%), PE (1 study, OR 1.19; 95% CI 0.58-2.42; P=0.64; Inot applicable), GDM (3 study, OR 0.79; 95% CI 0.52-1.20; P=0.27; I = 21%), LGA (1 study, OR 1.15; 95% CI 0.62-2.11; P=0.66; Inot applicable), macrosomia (1 study, OR 1.22; 95% CI 0.54-2.77; P=0.64; I not applicable), PTD (2 studies, OR 1.05; 95% CI 0.74-1.49; P=0.79; I = 0%), PPH (1 study, OR 1.49; 95% CI 0.85-2.62; P=0.17; Inot applicable), or PPROM (2 studies, OR 0.74; 95% CI 0.46-1.21; P=0.23; I = 0%) between programmed FET cycles and natural FET cycles.
CONCLUSIONS
The risks of HDPs, gestational hypertension, PE, GDM, LGA, macrosomia, SGA, PTD, placenta previa, PPROM, and PPH were increased in programmed FET cycles versus natural FET cycles with overall embryo transfer and blastocyst transfer, but the risks were not clear for cleavage-stage embryo transfer.
Topics: Pregnancy; Infant, Newborn; Humans; Female; Hypertension, Pregnancy-Induced; Fetal Macrosomia; Placenta; Placenta Previa; Pre-Eclampsia; Diabetes, Gestational; Embryo Transfer
PubMed: 37664838
DOI: 10.3389/fendo.2023.1186068 -
Journal of Cardiothoracic and Vascular... Nov 2023The authors performed a systematic review to evaluate the effect of pharmacologic therapy on pulmonary hypertension in the perioperative setting of elective cardiac...
OBJECTIVE
The authors performed a systematic review to evaluate the effect of pharmacologic therapy on pulmonary hypertension in the perioperative setting of elective cardiac surgery (PROSPERO CRD42023321041).
DESIGN
Systematic review of randomized controlled trials with a Bayesian network meta-analysis.
SETTING
The authors searched biomedical databases for randomized controlled trials on the perioperative use of inodilators and pulmonary vasodilators in adult cardiac surgery, with in-hospital mortality as the primary outcome and duration of ventilation, length of stay in the intensive care unit, stage 3 acute kidney injury, cardiogenic shock requiring mechanical support, and change in mean pulmonary artery pressure as secondary outcomes.
PARTICIPANTS
Twenty-eight studies randomizing 1,879 patients were included.
INTERVENTIONS
Catecholamines and noncatecholamine inodilators, arterial pulmonary vasodilators, vasodilators, or their combination were considered eligible interventions compared with placebo or standard care.
MEASUREMENTS AND MAIN RESULTS
Ten studies reported in-hospital mortality and assigned 855 patients to 12 interventions. Only inhaled prostacyclin use was supported by a statistically discernible improvement in mortality, with a number-needed-to-treat estimate of at least 3.3, but a wide credible interval (relative risk 1.26 × 10 - 0.7). Inhaled prostacyclin and nitric oxide were associated with a reduction in intensive care unit stay, and none of the included interventions reached a statistically evident difference compared to usual care or placebo in the other secondary clinical outcomes.
CONCLUSIONS
Inhaled prostacyclin was the only pharmacologic intervention whose use is supported by a statistically discernible improvement in mortality in the perioperative cardiac surgery setting as treatment of pulmonary hypertension. However, available evidence has significant limitations, mainly the low number of events and imprecision.
PubMed: 37652847
DOI: 10.1053/j.jvca.2023.07.041 -
International Journal of Surgery... Nov 2023Hepatocellular carcinoma (HCC) is the third-most lethal malignant tumor worldwide. The rapid development of immunotherapy utilizing immune checkpoint inhibitors for... (Meta-Analysis)
Meta-Analysis
Clinico-characteristics of patients which correlated with preferable treatment outcomes in immunotherapy for advanced hepatocellular carcinoma: a systematic review and meta-analysis.
BACKGROUND AND AIMS
Hepatocellular carcinoma (HCC) is the third-most lethal malignant tumor worldwide. The rapid development of immunotherapy utilizing immune checkpoint inhibitors for advanced HCC patients has been witnessed in recent years, along with numerous randomized clinical trials demonstrating the survival benefits for these individuals. This systematic review and meta-analysis aimed to identify specific clinico-pathological characteristics of advanced HCC patients that may lead to preferable responses to immunotherapy in terms of overall survival (OS), progression-free survival (PFS), and objective response rate (ORR).
METHODS
The included clinical trials were retrieved from PubMed, Embase, the Cochrane library, and the Web of Science databases published in English between 1 January 2002 and 20 October 2022. A systematic review and meta-analysis for first-line and second-line phase II/III studies were conducted on immunotherapy for patients with advanced HCC by using OS as the primary outcome measure, and PFS and ORR as the secondary outcome measures to obtain clinico-pathological characteristics of patients which might be preferable responses to programmed death-1 (PD-1) and programmed cell death-Ligand 1 (PD-L1) inhibitors. Toxicity and specific treatment-related adverse events (TRAEs) were also determined.
RESULTS
After screening 1392 relevant studies, 12 studies were included in this systematic review and meta-analysis to include 5948 patients. Based on the analysis of interaction, the difference in OS after first-line immunotherapy between the subgroups of viral hepatitis [hazard ratio (HR)=0.73 vs 0.87, P for interaction=0.02] and macrovascular invasion and/or extrahepatic spread (HR=0.73 vs 0.89, P for interaction=0.02) were significant. The difference in PFS between the subgroups of viral hepatitis was highly significant (pooled HR=0.55 vs 0.81, P for interaction=0.007). After second-line immunotherapy, the difference in ORR between the subgroups of Barcelona Clinic Liver Cancer was significant (pooled ES=0.12 vs 0.23, P for interaction=0.04). Compared with PD-L1 inhibitors, PD-1 inhibitors may have a higher probability to cause TRAEs. Diarrhea, increased aspartate aminotransferase, and hypertension were the top three TRAEs.
CONCLUSIONS
This systematic review and meta-analysis represents the first pilot study aimed at identifying crucial clinico-pathological characteristics of patients with advanced HCC that may predict favorable treatment outcomes in terms of OS, PFS, and ORR to immunotherapy. Findings suggest that patients with viral hepatitis positivity (especially hepatitis B virus) and macrovascular invasion and/or extrahepatic spread may benefit more in OS when treated with PD-1/PD-L1 immune checkpoint inhibitors.
Topics: Humans; Carcinoma, Hepatocellular; B7-H1 Antigen; Immune Checkpoint Inhibitors; Pilot Projects; Programmed Cell Death 1 Receptor; Liver Neoplasms; Treatment Outcome; Immunotherapy; Hepatitis, Viral, Human; Lung Neoplasms
PubMed: 37598406
DOI: 10.1097/JS9.0000000000000652 -
The Clinical Respiratory Journal Sep 2023Our understanding of the psychological impact of living with pulmonary hypertension (PH) is growing, particularly for how anxiety and depression present in this group....
INTRODUCTION
Our understanding of the psychological impact of living with pulmonary hypertension (PH) is growing, particularly for how anxiety and depression present in this group. There is evidence for the use of psychological interventions in other chronic lung conditions; however, trials focusing on adults with PH have yet to be subject to a systematic review.
METHODS
We systematically searched four databases for evidence examining the effectiveness of psychological interventions for adults with PH. A narrative approach has been used to present findings.
RESULTS
Overall, 186 unique articles were identified of which four were suitable. Data was gathered from 143 individuals. Cognitive behavioural therapy (CBT), metacognitive therapy (MCT) or counselling were investigated. All three studies reported a significant reduction in anxiety and depression, and some secondary outcomes were also associated with change.
DISCUSSION
The evidence supporting the use of psychological therapies for adults with PH is promising, although limited. There is an urgent need for more research in this area to better understand how we can support this clinical group.
Topics: Adult; Humans; Psychosocial Intervention; Hypertension, Pulmonary; Cognitive Behavioral Therapy; Anxiety Disorders; Anxiety; Depression
PubMed: 37581272
DOI: 10.1111/crj.13685 -
Cureus Aug 2023The most common cause of portal hypertension is liver cirrhosis. Portal hypertension causes many complications in cirrhotic patients; a significant complication is the... (Review)
Review
The Efficacy of Carvedilol in Comparison to Propranolol in Reducing the Hepatic Venous Pressure Gradient and Decreasing the Risk of Variceal Bleeding in Adult Cirrhotic Patients: A Systematic Review.
The most common cause of portal hypertension is liver cirrhosis. Portal hypertension causes many complications in cirrhotic patients; a significant complication is the formation of varices and the subsequent life-threatening variceal bleeding due to elevated portal venous pressures. Hepatic venous pressure gradient (HVPG) is the gold standard for measuring portal hypertension and guides management. Pharmacological treatments lower the HVPG, preventing the progression of varices and subsequent variceal bleeding. The pharmacological treatments frequently used in primary and secondary prophylaxis of a variceal bleed are nonselective beta (β)-adrenergic blockers. Propranolol was the first nonselective β-adrenergic blocker used for lowering HVPG and has been well studied. However, in the past decade, clinical trials have shown that carvedilol has been more effective. This study aims to establish whether carvedilol is more effective than propranolol in reducing the hepatic venous pressure gradient and decreasing the risk of variceal bleeding in adult cirrhotic patients. A systematic review has been conducted to gather relevant clinical trials comparing drugs and their effects on HVPG. Four databases: PubMed (Medical Literature Analysis and Retrieval System Online (MEDLINE)), Google Scholar, the Cochrane Library, and ScienceDirect, were analyzed, and records from January 1, 1999, to January 1, 2023, were chosen. There were a total of 1,235 potentially eligible records across the four databases. Using the eligibility criteria for this systematic review, seven studies of 533 patients were included. Across all seven clinical trials, it was found that carvedilol reduced HVPG more than propranolol and decreased the risk of variceal bleeding in adult cirrhotic patients.
PubMed: 37577269
DOI: 10.7759/cureus.43253 -
Journal of Clinical Medicine Aug 2023Between-sex differences in the presentation, risk factors, management, and outcomes of acute myocardial infarction (MI) are well documented. However, as such differences... (Review)
Review
Between-sex differences in the presentation, risk factors, management, and outcomes of acute myocardial infarction (MI) are well documented. However, as such differences are highly sensitive to cultural and social changes, there is a need to continuously re-evaluate the evidence. The present contemporary systematic review assesses the baseline characteristics of men and women presenting to secondary, tertiary, and quaternary centres with acute myocardial infarction (MI). Over 1.4 million participants from 18 studies, including primary prospective, cross sectional and retrospective observational studies, as well as secondary analysis of registry data are included in the study. The study showed that women were more likely than men to have a previous diagnosis of diabetes, hypertension, cerebrovascular disease, and heart failure. They also had lower odds of presenting with previous ischaemic heart disease and angina, dyslipidaemia, or a smoking history. Further work is necessary to understand the reasons for these differences, and the role that gender-specific risk factors may have in this context. Moreover, how these between-gender differences are implicated in management and outcomes also requires further work.
PubMed: 37568564
DOI: 10.3390/jcm12155163 -
Cardiology 2023Obesity is an important risk factor for the development of dyslipidemia, diabetes mellitus, hypertension, coronary artery disease, ventricular dysfunction, congestive... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Obesity is an important risk factor for the development of dyslipidemia, diabetes mellitus, hypertension, coronary artery disease, ventricular dysfunction, congestive heart failure (HF), stroke, and cardiac arrhythmias.
OBJECTIVES
This meta-analysis brings comprehensive evaluation about still controversial association between the body mass index (BMI) and the outcomes of acute coronary syndrome.
METHOD
PubMed/ScienceDirect databases were systematically searched for studies with baseline parameters, primary (HF, cardiogenic shock, cardiac arrest, reinfarction, stroke, death, total in-hospital complications) and secondary outcomes (reinfarction, stroke, death, total major adverse cardiovascular events [MACE]) in relation to BMI strictly classified into four groups (underweight [<18.5 kg/m2], normal weight [18.5-24.9 kg/m2], overweight [25.0-29.9 kg/m2], and obese [≥30.0 kg/m2], grouped into mildly obese [30.0-34.9 kg/m2] and severely obese [≥35.0 kg/m2]).
RESULTS
We included 24 studies, with 585,919 participants (55.5% males), aged 66.8 years. Underweight was negatively associated with hypertension, hyperlipidemia and diabetes, and positively with primary outcomes {HF (odds ratio [OR] = 1.37, confidence interval [CI] [1.15-1.63]), cardiogenic shock (OR = 1.43, CI [1.04-1.98]), stroke (OR = 1.21, CI [1.05-1.40]), overall death (OR = 1.64, CI [1.20-2.26]), total in-hospital complications (OR = 1.39, CI [1.24-1.56])} and secondary outcomes during 34-month follow-up {cardiovascular/overall death (OR = 3.78, CI [1.69-8.49]/OR = 2.82, CI [2.29-3.49]), respectively, total MACE (OR = 2.77, CI [2.30-3.34])} (for all p < 0.05). Obesity had positive association with hypertension, hyperlipidemia, diabetes and smoking, and negative with primary outcomes {reinfarction (OR = 0.83, CI [0.76-0.91]), stroke (OR = 0.67, CI [0.54-0.85]), overall death (OR = 0.55, CI [0.49-0.63]), total in-hospital complications (OR = 0.81, CI [0.70-0.93])} and secondary outcomes {cardiovascular/overall death (OR = 0.77, CI [0.66-0.88]/OR = 0.62, CI [0.53-0.72]), respectively, total MACE (OR = 0.63, CI [0.60-0.77])} (for all p < 0.05). This negative association with several primary outcomes (cardiogenic shock, overall death, total in-hospital complications) and secondary outcomes (cardiovascular/overall death, total MACE) was more pronounced in mild obesity (p < 0.05). These results give an "obesity paradox" with a bimodal pattern (slightly U-shaped).
CONCLUSIONS
Obesity is positively associated with traditional cardiovascular risk factors and negatively with primary and secondary outcomes, which confirms the persistence of overall "obesity paradox."
Topics: Male; Humans; Female; Acute Coronary Syndrome; Follow-Up Studies; Shock, Cardiogenic; Obesity Paradox; Thinness; Obesity; Risk Factors; Hypertension; Heart Failure; Stroke; Hyperlipidemias; Diabetes Mellitus; Body Mass Index
PubMed: 37552961
DOI: 10.1159/000531985