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1.
Nicorandil improves clinical outcomes in patients with stable angina pectoris requiring PCI: a systematic review and meta-analysis of 14 randomized trials.
Li, Y, Liu, H, Peng, W, Song, Z
Expert review of clinical pharmacology. 2018;(9):855-865
Abstract
Clinical trials concerning the effects of nicorandil in stable coronary artery disease (CAD) remain controversial. This study sought to evaluate the clinical outcomes of nicorandil following elective percutaneous coronary intervention (PCI). Areas covered: A meta-analysis including eligible randomized controlled trials (RCTs) with data on the nicorandil in stable CAD from Pubmed, EMBase, and Cochrane library (up to March 2018) was conducted. The primary end points were postprocedural incidence of myocardial infarction (MI) and contrast-induced nephropathy (CIN). The second end point was major adverse cerebrovascular and cardiovascular events (MACCE). Fourteen RCTs with a total of 1947 elective CAD patients were selected. Nicorandil significantly reduced the incidence of MI [n = 8; relative risk (RR) = 0.58; P = 0.001; I2 = 33.7%], and CIN (n = 5; RR = 0.36; P < 0.00001; I2 = 15.4%). However, There was no lowered risk of MACCE in nicorandil-treated patients [n = 10; odds RR = 0.75; P = 0.19; I2 = 0.0%]. Subsequent trial sequential analyses confirmed the effect of nicorandil on MI and CIN in PCI. Expert commentary: The present systematic review and meta-analysis suggests that nicorandil could improve clinical outcomes in terms of perioperative MI and CIN. However, the effect of nicorandil on the MACCE risk is not obvious. Future high-quality, large-scale clinical trials should majorly concern about the long-term clinical effect of nicorandil.
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2.
Magnesium status and magnesium therapy in cardiac surgery: A systematic review and meta-analysis focusing on arrhythmia prevention.
Fairley, JL, Zhang, L, Glassford, NJ, Bellomo, R
Journal of critical care. 2017;:69-77
Abstract
PURPOSE To investigate magnesium as prophylaxis or treatment of postoperative arrhythmias in cardiac surgery (CS) patients. To assess impact on biochemical and patient-centered outcomes. MATERIALS AND METHODS We searched MEDLINE, CENTRAL and EMBASE electronic databases from 1975 to October 2015 using terms related to magnesium and CS. English-Language RCTs were included involving adults undergoing CS with parenterally administered magnesium to treat or prevent arrhythmias, compared to control or standard antiarrythmics. We extracted incidence of postoperative arrhythmias, termination following magnesium administration and secondary outcomes (including mortality, length of stay, hemodynamic parameters, biochemistry). RESULTS Thirty-five studies were included, with significant methodological heterogeneity. Atrial fibrillation (AF) was most commonly reported, followed by ventricular, supraventricular and overall arrhythmia frequency. Magnesium appeared to reduce AF (RR 0.69, 95% confidence interval (95%CI) 0.56-0.86, p=0.002), particularly postoperatively (RR 0.51, 95%CI 0.34-0.77, p=0.003) for longer than 24h. Maximal benefit was seen with bolus doses up to 60mmol. Magnesium appeared to reduce ventricular arrhythmias (RR=0.46, 95%CI 0.24-0.89, p=0.004), with a trend to reduced overall arrhythmias (RR=0.80, 95%CI 0.57-1.12, p=0.191). We found no mortality effect or significant increase in adverse events. CONCLUSIONS Magnesium administration post-CS appears to reduce AF without significant adverse events. There is limited evidence to support magnesium administration for prevention of other arrhythmias.
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3.
Role of ranolazine in the prevention and treatment of atrial fibrillation: A meta-analysis of randomized clinical trials.
Gong, M, Zhang, Z, Fragakis, N, Korantzopoulos, P, Letsas, KP, Li, G, Yan, GX, Liu, T
Heart rhythm. 2017;(1):3-11
Abstract
BACKGROUND Randomized controlled trials (RCTs) on the use of ranolazine (RN) for prevention and cardioversion of atrial fibrillation (AF) have yielded conflicting results. OBJECTIVE The purpose of this study was to conduct a meta-analysis of RCTs to examine the potential role of RN in the prevention and cardioversion of AF. METHODS PubMed and EMBASE were searched until June 2016. Of 484 initially identified studies, 8 RCTs were finally analyzed. RESULTS The analysis of RCTs showed that RN significantly reduced the incidence of AF compared to the control group in various clinical settings, such as after cardiac surgery, in acute coronary syndromes, and post-electrical cardioversion of AF (relative risk [RR] 0.67, 95% confidence interval [CI] 0.52-0.87, Z = 3.06, P = .002). Furthermore, a higher conversion rate of AF from the combined use of RN and amiodarone compared to amiodarone alone (RR 1.23, 95% CI 1.08-1.40, Z = 3.07, P = .002) was clear, with conversion time significantly shorter in RN plus amiodarone compared to the amiodarone group (weighted mean difference [WMD] = -10.38 hours, 95% CI -18.18 to -2.57, Z = 2.61, P = .009). CONCLUSION Our meta-analysis suggests that RN may be effective in AF prevention, whereas it potentiates and accelerates the conversion effect of amiodarone of recent-onset AF. Larger RCTs with long-term follow-up in diverse clinical settings are needed to further clarify the impact of RN on AF therapy.
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4.
Meta-analysis of ascorbic acid for prevention of postoperative atrial fibrillation after cardiac surgery.
Baker, WL, Coleman, CI
American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2016;(24):2056-2066
Abstract
PURPOSE Results of a systematic review and meta-analysis of published data on use of ascorbic acid to prevent postoperative atrial fibrillation (POAF) after cardiac surgery are presented. METHODS MEDLINE and other sources were searched for reports on trials evaluating the effects of preoperative and/or postoperative use of ascorbic acid in patients undergoing cardiac surgery. For each study selected for meta-analysis, an assessment for risks of methodological bias was performed. Data on POAF frequency and length of stay (LOS) outcomes were pooled and analyzed via random-effects modeling. RESULTS The 11 identified studies involved patients receiving coronary artery bypass grafts with or without valve replacement; both i.v. and oral ascorbic acid formulations were used. Analysis of pooled outcomes data on treatment and control groups indicated that ascorbic acid prophylaxis was associated with reductions in POAF frequency (odds ratio, 0.44; 95% confidence interval [CI], 0.32 to 0.61), intensive care unit (ICU) LOS (difference in means, -0.24 day; 95% CI, -0.45 to -0.03 day), and total hospital LOS (difference in means, -0.94 day; 95% CI, -1.65 to -0.23 day). Significant statistical, methodological, and clinical heterogeneity were observed. CONCLUSION A meta-analysis revealed that, compared with use of a placebo or a nonplacebo control, perioperative administration of ascorbic acid to patients undergoing cardiac surgery was associated with a reduced frequency of POAF and a shorter ICU LOS and total hospital LOS.
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5.
Postoperative atrial fibrillation prophylaxis after lung surgery: systematic review and meta-analysis.
Riber, LP, Larsen, TB, Christensen, TD
The Annals of thoracic surgery. 2014;(6):1989-97
Abstract
BACKGROUND Atrial fibrillation after thoracic surgery is frequent and increases morbidity and mortality. A number of trials have investigated medical prophylaxis for the prevention of atrial fibrillation after surgery for lung cancer. However, the literature is diverse and hence difficult to review. The aim of this study was to evaluate the safety and efficacy of reducing the risk of postoperative atrial fibrillation by the use of medical prophylaxis in patients undergoing surgery for lung cancer. METHODS A systematic review and meta-analysis of randomized, controlled trials investigating prophylactic medical interventions to reduce the risk of postoperative atrial fibrillation was performed. RESULTS A total number of 10 trials were identified. A significant reduction in the risk of postoperative atrial fibrillation was found with a relative risk of 0.53 (95% confidence interval, 0.42 to 0.67) and a number needed-to-treat of 8.5 (95% confidence interval, 6.4 to 13.3). Amiodarone was found to be the most effective prophylactic agent with a relative risk of 0.32 (95% confidence interval, 0.19 to 0.50) and a number needed-to-treat of 4.8 (95% confidence interval, 3.7 to 7.6) and regarded as safe, with no severe adverse events registered. The risk of atrial fibrillation was overall reduced from 25.1% to 13.4% (p < 0.001) and for amiodarone as a single therapy from 30.4% to 9.6% (p < 0.001). CONCLUSIONS Medical prophylaxis with calcium-channel blockers, magnesium sulfate, or amiodarone significantly reduces the risk of developing atrial fibrillation after lung reduction surgery. However, amiodarone and magnesium sulfate were the most effective and safest drugs causing no increased risk of adverse events.
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6.
Efficacy of N-acetylcysteine in preventing atrial fibrillation after cardiac surgery: a meta-analysis of published randomized controlled trials.
Liu, XH, Xu, CY, Fan, GH
BMC cardiovascular disorders. 2014;:52
Abstract
BACKGROUND Atrial fibrillation is a common complication after cardiac surgery. The aim of this study is to evaluate whether N-acetylcysteine (NAC) could prevent postoperative atrial fibrillation (POAF). METHODS PubMed, Embase and Cochrane Center Register of Controlled Trials were searched from the date of their inception to 1 July 2013 for relevant randomized controlled trials (RCTs), in which NAC was compared with controls for adult patients undergoing cardiac surgery. Outcome measures comprised the incidence of POAF, all-cause mortality, length of intensive care unit (ICU) stay, hospital length of stay, and the incidence of cerebrovascular events. The meta-analysis was performed with the fixed-effect model or random-effect model according to the heterogeneity. RESULTS We retrieved ten studies enrolling a total of 1026 patients. Prophylactic NAC reduced the incidence of POAF (OR 0.56; 95% CI 0.40 to 0.77; P < 0.001) and all-cause mortality (OR 0.40; 95% CI 0.17 to 0.93; P = 0.03) compared with controls, but failed to reduce the stay in ICU and overall stay in hospital. No difference in the incidence of cerebrovascular events was observed. CONCLUSIONS Prophylactic use of NAC could reduce the incidence of POAF and all-cause mortality in adult patients undergoing cardiac surgery. However, larger RCTs evaluating these and other postoperative complication endpoints are needed.
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7.
Antioxidant supplementations for prevention of atrial fibrillation after cardiac surgery: an updated comprehensive systematic review and meta-analysis of 23 randomized controlled trials.
Ali-Hassan-Sayegh, S, Mirhosseini, SJ, Rezaeisadrabadi, M, Dehghan, HR, Sedaghat-Hamedani, F, Kayvanpour, E, Popov, AF, Liakopoulos, OJ
Interactive cardiovascular and thoracic surgery. 2014;(5):646-54
Abstract
This systematic review with meta-analysis sought to determine the impact of antioxidants (N-acetylcysteine [NAC], polyunsaturated fatty acids [PUFAs] and vitamins) on incidence of postoperative atrial fibrillation (POAF) and duration of length of hospital stay. Medline, Embase, Elsevier, Sciences online database and Google Scholar literature search was made for studies in randomized controlled trials. The effect sizes measured were odds ratio (OR) for categorical variable and standard mean difference (SMD) with 95% confidence interval (CI) for calculating differences between mean values of duration of hospitalization in intervention and control groups. A value of P < 0.1 for Q-test or I(2) > 50% indicated significant heterogeneity between the studies. Literature search of all major databases retrieved 355 studies. After screening, a total of 23 trials were identified that reported outcomes of 4278 patients undergoing cardiac surgery. Pooled effects estimates on POAF showed a significant reduction after NAC (OR: 0.56, 95% CI: 0.40-0.77, P < 0.001), PUFA (OR: 0.84, 95% CI: 0.71-0.99, P = 0.03) and vitamin C treatment (OR: 0.50, 95% CI: 0.27-0.91, P = 0.02). Hospital length of stay was not reduced after NAC therapy (SMD: 0.082, 95% CI -0.09 to 0.25, P = 0.3), but could be decreased with PUFA (SMD: -0.185, 95% CI: -0.35 to -0.018, P = 0.03) and vitamin C (SMD: -0.325, 95% CI -0.50 to -0.14, P < 0.01). In conclusion, perioperative antioxidant supplementations with NAC, PUFA and vitamin C prevent atrial fibrillation after cardiac surgery. Moreover, PUFA and vitamin C are capable to reduce hospital stay, whereas NAC lacks this capacity.
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8.
N-3 polyunsaturated fatty acids to prevent atrial fibrillation: updated systematic review and meta-analysis of randomized controlled trials.
Mariani, J, Doval, HC, Nul, D, Varini, S, Grancelli, H, Ferrante, D, Tognoni, G, Macchia, A
Journal of the American Heart Association. 2013;(1):e005033
Abstract
BACKGROUND Previous studies have suggested that n-3 polyunsaturated fatty acids (n-3 PUFAs) have antiarrhythmic effects on atrial fibrillation (AF). We aimed to assess the effects of therapy with n-3 PUFAs on the incidence of recurrent AF and on postoperative AF. METHODS AND RESULTS Electronic searches were conducted in Web of Science, Medline, Biological Abstracts, Journal Citation Reports, and the Cochrane Central Register of Controlled Trials databases. In addition, data from the recently completed FORωARD and OPERA trials were included. We included randomized controlled trials comparing treatment with n-3 PUFAs versus control to (1) prevent recurrent AF in patients who underwent reversion of AF or (2) prevent incident postoperative AF after cardiac surgery. Of identified studies, 12.9% (16 of 124) were included, providing data on 4677 patients. Eight studies (1990 patients) evaluated n-3 PUFA effects on AF recurrence among patients with reverted AF and 8 trials (2687 patients) on postoperative AF. Pooled risk ratios through random-effects models showed no significant effects on AF recurrence (RR, 0.95; 95% CI, 0.79 to 1.13; I(2), 72%) or on postoperative AF (0.86; 95% CI, 0.71 to 1.04; I(2), 53.1%). A funnel plot suggested publication bias among postoperative trials but not among persistent AF trials. Meta-regression analysis did not find any relationship between doses and effects (P=0.887 and 0.833 for recurrent and postoperative AF, respectively). CONCLUSIONS Published clinical trials do not support n-3 PUFAs as agents aimed at preventing either postoperative or recurrent AF. CLINICAL TRIAL REGISTRATION URL: http://www.crd.york.ac.uk/PROSPERO. Unique Identifier: CRD42012002199.
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9.
Antiarrhythmia drugs for cardiac arrest: a systemic review and meta-analysis.
Huang, Y, He, Q, Yang, M, Zhan, L
Critical care (London, England). 2013;(4):R173
Abstract
INTRODUCTION Antiarrhythmia agents have been used in the treatment of cardiac arrest, and we aimed to review the relevant clinical controlled trials to assess the effects of antiarrhythmics during cardiopulmonary resuscitation. METHODS We searched databases including Cochrane Central Register of Controlled Trials; MEDLINE, and EMBASE. Clinical controlled trials that addressed the effects of antiarrhythmics (including amiodarone, lidocaine, magnesium, and other new potassium-channel blockers) on the outcomes of cardiac arrest were included. Data were collected independently by two authors. The risk ratio of each outcome was collected, and meta-analysis was used for data synthesis if appropriate. Heterogeneity was assessed with the χ² test and the I² test. RESULTS Ten randomized controlled trials and seven observational trials were identified. Amiodarone (relative risk (RR), 0.82; 95% confidence interval (CI), 0.54 to 1.24), lidocaine (RR, 2.26; 95% CI, 0.93 to 5.52), magnesium (RR, 0.82; 95% CI, 0.54 to 1.24) and nifekalant were not shown to improve the survival to hospital discharge compared with placebo, but amiodarone, lidocaine, and nifekalant were shown to be beneficial to initial resuscitation, assessed by the rate of return of spontaneous circulation and survival to hospital admission, with amiodarone being superior to lidocaine (RR, 1.28; 95% CI, 0.57 to 2.86) and nifekalant (RR, 0.50; 95% CI, 0.19 to 1.31). Bretylium and sotalol were not shown to be beneficial. CONCLUSIONS Our review suggests that when administered during resuscitation, antiarrhythmia agents might not improve the survival to hospital discharge, but they might be beneficial to initial resuscitation. This is consistent with the AHA 2010 guidelines for resuscitation and cardiovascular emergency, but more studies with good methodologic quality and large numbers of patients are still needed to make further assessment.
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10.
Nicorandil in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: a systematic review and meta-analysis.
Wu, M, Huang, Z, Xie, H, Zhou, Z
PloS one. 2013;(10):e78231
Abstract
BACKGROUND Nicorandil, as an adjunctive therapy with primary percutaneous coronary intervention (PCI), had controversial benefits in cardioprotection in patients with acute myocardial infarction (AMI). METHODS AND RESULTS We performed a systematic review of randomized controlled trials (RCTs) comparing treatment with nicorandil prior to reperfusion therapy with control (placebo or no nicorandil) in patients who suffered from AMI and performed primary PCI. PubMed, EMBASE and CENTRAL databases and other sources were searched without language and publication restriction. 14 trials involving 1680 patients were included into this meta-analysis. Nicorandil significantly reduced the incidence of thrombolysis in myocardial infarction (TIMI) flow grade ≤ 2 (risk ratio [RR], 0.57; 95% confidence interval [CI]: 0.42 to 0.79), the Timi frame count (TFC) (mean difference [MD], -5.19; 95% CI: -7.13 to -3.26), increased left ventricular ejection fraction (LVEF) (%) (MD, 3.08; 95% CI: 0.79 to 5.36), and reduced the incidence of ventricular arrhythmia (RR, 0.53; 95% CI: 0.37 to 0.76) and congestive heart failure (CHF) (RR, 0.41; 95% CI: 0.22 to 0.75). No difference in the pear creatine kinase (CK) value (MD, -290.19; 95% CI: -793.75 to 213.36) or cardiac death (RR, 0.39; 95% CI: 0.09 to 1.67) was observed. CONCLUSIONS Nicorandil prior to reperfusion is associated with improvement of coronary reflow as well as suppression of ventricular arrhythmia, and further improves left ventricular function in patients who suffered from AMI and underwent primary PCI. But the definite clinical benefits of nicorandil were not found, which may be due to the small sample size of the selected studies.