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1.
Efficacy of high-dose atorvastatin or rosuvastatin loading in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials with GRADE qualification of available evidence.
Borovac, JA, Leth-Olsen, M, Kumric, M, D'Amario, D, Schwarz, K, Glavas, D, Bozic, J
European journal of clinical pharmacology. 2022;(1):111-126
Abstract
PURPOSE We aimed to summarize current evidence regarding the impact of a high-dose statin loading before percutaneous coronary intervention (PCI) on short-term outcomes in patients presenting with the acute coronary syndrome (ACS). METHODS This meta-analysis was based on a search of the MEDLINE, Cochrane Central Register of Controlled Trials, Ovid Journals, and SCOPUS for randomized controlled trials that compared high-dose atorvastatin or rosuvastatin with no or low-dose statin administered before planned PCI in statin-naive patients with ACS. The primary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and all-cause mortality at 30 days. Prespecified subanalyses were performed with respect to statin and ACS type. RESULTS A total of eleven trials enrolling 6291 patients were included, of which 75.4% received PCI. High-dose statin loading was associated with an overall 43% relative risk (RR) reduction in MACCE at 30 days (RR 0.57, 95% CI 0.41-0.77) in whole ACS population. This effect was primarily driven by the 39% reduction in the occurrence of MI (RR 0.61, 95% CI 0.46-0.80). No significant effect on all-cause mortality reduction was observed (RR 0.92, 95% CI 0.67-1.26). In the setting of ST-elevation myocardial infarction (STEMI), atorvastatin loading was associated with a 33% reduction in MACCE (RR 0.67, 95% CI 0.48-0.94), while in non-ST-elevation myocardial infarction ACS (NSTE-ACS), rosuvastatin loading was associated with 52% reduction in MACCE at 30 days (RR 0.48, 95% CI 0.34-0.66). The level of evidence as qualified with GRADE was low to high, depending on the outcome. CONCLUSION A high-dose loading of statins before PCI in patients with ACS reduces MACCE and reduces the risk of MI with no impact on mortality at 30 days. Atorvastatin reduces MACCE in STEMI while rosuvastatin reduces MACCE in NSTE-ACS at 30 days.
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2.
Tailored Versus Standard Hydration to Prevent Acute Kidney Injury After Percutaneous Coronary Intervention: Network Meta-Analysis.
Moroni, F, Baldetti, L, Kabali, C, Briguori, C, Maioli, M, Toso, A, Brilakis, ES, Gurm, HS, Bagur, R, Azzalini, L
Journal of the American Heart Association. 2021;(13):e021342
Abstract
Background Contrast-induced acute kidney injury (CI-AKI) is a serious complication after percutaneous coronary intervention. The mainstay of CI-AKI prevention is represented by intravenous hydration. Tailoring infusion rate to patient volume status has emerged as advantageous over fixed infusion-rate hydration strategies. Methods and Results A systematic review and network meta-analysis with a frequentist approach were conducted. A total of 8 randomized controlled trials comprising 2312 patients comparing fixed versus tailored hydration strategies to prevent CI-AKI after percutaneous coronary intervention were included in the final analysis. Tailored hydration strategies included urine flow rate-guided, central venous pressure-guided, left ventricular end-diastolic pressure-guided, and bioimpedance vector analysis-guided hydration. Primary endpoint was CI-AKI incidence. Safety endpoint was incidence of pulmonary edema. Urine flow rate-guided and central venous pressure-guided hydration were associated with a lower incidence of CI-AKI compared with fixed-rate hydration (odds ratio [OR], 0.32 [95% CI, 0.19-0.54] and OR, 0.45 [95% CI, 0.21-0.97]). No significant difference in pulmonary edema incidence was observed between the different hydration strategies. P score analysis showed that urine flow rate-guided hydration is advantageous in terms of both CI-AKI prevention and pulmonary edema incidence when compared with other approaches. Conclusions Currently available hydration strategies tailored on patients' volume status appear to offer an advantage over guideline-supported fixed-rate hydration for CI-AKI prevention after percutaneous coronary intervention. Current evidence suggests that urine flow rate-guided hydration as the most convenient strategy in terms of effectiveness and safety.
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3.
The role of probucol preventing contrast-induced nephropathy in patients undergoing invasive coronary procedures - Systematic review and meta-analysis of randomized controlled trials.
Pranata, R, Yonas, E, Vania, R, Lukito, AA
Turk Kardiyoloji Dernegi arsivi : Turk Kardiyoloji Derneginin yayin organidir. 2021;(1):51-59
Abstract
OBJECTIVE The aim of this meta-analysis was to synthesize the latest evidence on the effect of probucol on the incidence of contrast-induced nephropathy (CIN) in patients undergoing coronary angiography (CAG)/percutaneous coronary intervention (PCI). METHODS A systematic literature search of PubMed, ScienceDirect, EuropePMC, ProQuest, and Clinicaltrials. gov was performed to retrieve studies that assessed probucol and CIN in CAG/PCI. RESULTS Four studies that compared probucol with hydration alone, comprising 1270 subjects, were identified and analyzed. There was no significant difference between probucol and control groups in the baseline level of creatinine and at 48 hours; however, a significant difference was observed at 72 hours (mean difference: -3.87 μmol/L; 95% confidence interval [CI]: -6.58, -1.15; p=0.005). The meta-analysis indicated that probucol did not reduce the CIN incidence (odds ratio [OR]: 0.46; 95% CI: 0.20, 1.08; p=0.08). After performing a leave-one-out sensitivity analysis, removal of a study resulted in a lower risk of CIN (OR: 0.33; 95% CI: 0.19, 0.56; p<0.001). Probucol did not reduce the CIN incidence in a pooled adjusted effect estimate (OR: 0.75; 95% CI: 0.15, 3.87; p=0.73). There was no significant difference in the rate of major adverse events between the 2 groups (OR: 0.39; 95% CI: 0.05, 3.05; p=0.37). Funnel plot results were asymmetrical, indicating possible publication bias. Grading of Recommendations, Assessment, Development and Evaluations qualification demonstrated a low and very low certainty of evidence in unadjusted and adjusted effect estimates, respectively. CONCLUSION Probucol did not reduce the incidence of CIN; however, due to the low certainty of evidence, further study is required for a definite conclusion. Although the p value was not significant, the confidence interval showed a nonsignificant trend toward benefit. However, this trend might have been due to publication bias.
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4.
Double or triple antithrombotic therapy after coronary stenting and atrial fibrillation: A systematic review and meta-analysis of randomized clinical trials.
Andò, G, Costa, F
International journal of cardiology. 2020;:95-102
Abstract
AIMS: Double or triple antithrombotic therapy (DAT/TAT) including or excluding aspirin in association with oral anticoagulant and P2Y12 inhibitor are currently two available options in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). We evaluated efficacy and safety outcomes for DAT vs. TAT. METHODS AND RESULTS Four non-vitamin K oral anticoagulants (NOAC)-based randomized controlled trials comparing DAT vs. TAT with a total of 10,938 patients were pooled. Bleeding events occurred more frequently than ischemic events. DAT as compared to TAT was associated to an increased risk of stent thrombosis (RR 1.54, 95% CI 1.10-2.14; p = 0.03), myocardial infarction (RR 1.23, 95% CI 1.04-1.46; p = 0.03) and cardiovascular mortality (RR 1.09, 95% CI 1.01-1.19; p = 0.04) and to a reduced risk of ISTH major or clinically relevant non-major bleeding (RR 0.59, 95% CI 0.62-0.93; p = 0.03). A consistent effect was observed in all safety endpoints. Intracranial haemorrhage was numerically reduced by DAT. No difference for all-cause death was observed. CONCLUSION Antithrombotic treatment in patients with AF undergoing PCI represents a trade-off between ischemia and bleeding. A careful patient selection based on baseline ischemic and bleeding risk may optimize the net clinical balance in this population.
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5.
Dual anti-thrombotic treatment with direct anticoagulants improves clinical outcomes in patients with Atrial Fibrillation with ACS or undergoing PCI. A systematic review and meta-analysis.
De Rosa, S, Sabatino, J, Polimeni, A, Sorrentino, S, Indolfi, C
PloS one. 2020;(7):e0235511
Abstract
BACKGROUND There is recent new evidence regarding the combined use of direct oral antiocoagulants and antiplatelet agents in patients with Atrial Fibrillation undergoing PCI. PURPOSE To compare the efficacy of dual antithrombotic treatment (DAT) including a direct oral anticoagulant (DOAC) and an antiplatelet agent versus triple antithrombotic treatment (TAT) with a vitamin K antagonist (VKA). DATA SOURCES PubMed, SCOPUS and Google Scholar from through 09/09/2019; references of eligible studies; relevant scientific sessions abstracts and cardiology websites. STUDY SELECTION Randomized controlled trials that compared DAT including a DOAC with TAT including a VKA and that reported at least the rates of stroke, Stent thrombosis and bleeding. DATA EXTRACTION Two investigators independently extracted study data and assessed study quality. DATA SYNTHESIS Four randomized trials that compared DAT including a DOAC with TAT including a VKA were available. Among these, one trial included two independent treatment arms with different DOAC dose, both compared against TAT. For this reason, the two arms were treated independently, resulting in 5 randomized comparisons available for meta-analysis, with a total of 8654 patients involved. The primary safety endpoint was significantly lower in the DAT arm (14.4%) compared to the TAT arm (23%) (RD = -0.08; p<0.001). In addition, we found no significant difference in the incidence of stroke between the treatment arms (p = 0.23). Similarly, no significant difference in the incidence of Stent Thrombosis between the treatment arms (p = 0.08). LIMITATIONS All trials included were open-label, even though data were blindly analyzed. Qualifying criteria are heterogeneous. CONCLUSIONS Compared TAT including a VKA, a therapeutic DAT regimen including a DOAC was associated with a significant reduction of the primary safety endpoint in AF patients undergoing PCI with stent implantation for an ACS or chronic coronary syndrome, while no significant difference was found in the rate of ischemic adverse events, including stroke, acute myocardial infarction or stent thrombosis.
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6.
Influence of LDL-Cholesterol Lowering on Cardiovascular Outcomes in Patients With Diabetes Mellitus Undergoing Coronary Revascularization.
Farkouh, ME, Godoy, LC, Brooks, MM, Mancini, GBJ, Vlachos, H, Bittner, VA, Chaitman, BR, Siami, FS, Hartigan, PM, Frye, RL, et al
Journal of the American College of Cardiology. 2020;(19):2197-2207
Abstract
BACKGROUND Elevated low-density lipoprotein cholesterol (LDL-C) is associated with increased cardiovascular events, especially in high-risk populations. OBJECTIVES This study sought to evaluate the influence of LDL-C on the incidence of cardiovascular events either following a coronary revascularization procedure (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) or optimal medical therapy alone in patients with established coronary heart disease and type 2 diabetes (T2DM). METHODS Patient-level pooled analysis of 3 randomized clinical trials was undertaken. Patients with T2DM were categorized according to the levels of LDL-C at 1 year following randomization. The primary endpoint was major adverse cardiac or cerebrovascular events ([MACCE] the composite of all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke). RESULTS A total of 4,050 patients were followed for a median of 3.9 years after the index 1-year assessment. Patients whose 1-year LDL-C remained ≥100 mg/dl experienced higher 4-year cumulative risk of MACCE (17.2% vs. 13.3% vs. 13.1% for LDL-C between 70 and <100 mg/dl and LDL-C <70 mg/dl, respectively; p = 0.016). When compared with optimal medical therapy alone, patients with PCI experienced a MACCE reduction only if 1-year LDL-C was <70 mg/dl (hazard ratio: 0.61; 95% confidence interval: 0.40 to 0.91; p = 0.016), whereas CABG was associated with improved outcomes across all 1-year LDL-C strata. In patients with 1-year LDL-C ≥70 mg/dl, patients undergoing CABG had significantly lower MACCE rates as compared with PCI. CONCLUSIONS In patients with coronary heart disease with T2DM, lower LDL-C at 1 year is associated with improved long-term MACCE outcome in those eligible for either PCI or CABG. When compared with optimal medical therapy alone, PCI was associated with MACCE reductions only in those who achieved an LDL-C <70 mg/dl.
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7.
The effect of nicorandil in patients with acute myocardial infarction undergoing percutaneous coronary intervention: a systematic review and meta-analysis.
Ji, Z, Zhang, R, Lu, W, Ma, G, Qu, Y
Irish journal of medical science. 2020;(1):119-131
Abstract
AIMS: To study the effect of nicorandil on prognosis of patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). METHODS We retrieved literatures from Web of Science, Pubmed, Embase, and Cochrane Library. The retrieval time was limited from inception to December 2018. RESULTS Nineteen randomized controlled trials involving 2176 patients were finally selected for this study. Meta-analysis showed that nicorandil can significantly reduce corrected TIMI frame count (cTFC) (WMD = - 5.27; 95% CI (- 6.61, - 3.93); P < 0.00001) and improve the no-reflow or slow-reflow phenomenon of coronary arteries (thrombolysis in myocardial infarction (TIMI) ≤ 2) (RR = 0.52; 95% CI (0.40, 0.68); P < 0.001). Compared with control group, nicorandil group has higher left ventricular ejection fraction (LVEF) (WMD = 3.42; 95% CI (1.32, 5.51); P = 0.001), and subgroup analysis showed that sex ratio was one source of heterogeneity (male/female ratio < 4 for low M/F group, M/F > 4 for high M/F group). In the low M/F group, LVEF in nicorandil group was increased significantly (WMD = 4.61; 95% CI (3.03, 6.20); P < 0.001), while there was no significant difference in LVEF between two groups in the high M/F group (WMD = 1.00; 95% CI (- 1.09, 3.09); P = 0.350). In addition, the incidence of in-hospital reperfusion arrhythmia (RR = 0.47; 95% CI (0.36, 0.63); P < 0.00001) and major adverse cardiovascular events (MACEs) (RR = 0.49; 95% CI (0.35, 0.69); P < 0.001) were significantly lower in the nicorandil group than that in control group. CONCLUSIONS Nicorandil can improve coronary microcirculation and left ventricular function of patients with AMI after PCI. Interestingly, female patients may benefit more from nicorandil than male patients in improving heart function.
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8.
Antithrombotic regimen for patients with cardiac indication for dual antiplatelet therapy and anticoagulation: a meta-analysis of randomized trials.
Liao, YWB, Wang, TKM
Coronary artery disease. 2020;(3):260-265
Abstract
OBJECTIVES The optimal antithrombotic strategy for patients with a long-term indication for anticoagulation and acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) remains controversial. This meta-analysis aims to compare randomised trials' outcomes of these patients, focussing on dual versus triple antithrombotic and non vitamin K oral anticoagulants (NOACs) versus vitamin K oral anticoagulants regimens. METHODS Medline, Embase and Cochrane databases were searched from January 1980 to March 2019 yielding 309 articles, and after careful screening, five randomized trials totalling 10 643 patients were included for analysis. RESULTS Dual antithrombotic regimens were associated with significantly less thrombolysis in myocardial infarction (TIMI) major and minor bleeding [odds ratio (OR) 0.53, 95% confidence interval (CI) 0.40-0.71], with no significant difference in major adverse cardiovascular events (OR 0.93, 95% CI 0.72-1.22) or all-cause mortality (OR 0.89, 95% CI 0.61-1.19). NOAC regimens had significantly lower TIMI major and minor bleeding (OR 0.58, 95% CI 0.43-0.78) and intracranial bleeding (OR 0.33, 95% CI 0.16-0.66), with similar rates of major adverse cardiovascular events (OR 1.00, 95% CI 0.86-1.16) and all-cause mortality (OR 1.01, 95% CI 0.81-1.26). CONCLUSION Dual antithrombotic and NOAC regimens have reduced bleeding without compromising the risk of cardiovascular events or mortality, and should be preferred for patients with ACS or PCI also needing long-term anticoagulation.
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9.
Effects of Intracoronary Nicorandil on Myocardial Microcirculation and Clinical Outcomes in Patients with Acute Myocardial Infarction: A Meta-Analysis of Randomized Controlled Trials.
Shi, L, Chen, L, Qi, G, Tian, W, Zhao, S
American journal of cardiovascular drugs : drugs, devices, and other interventions. 2020;(2):191-198
Abstract
BACKGROUND The amelioration of myocardial reperfusion in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PPCI) remains a significant issue. OBJECTIVE We conducted a meta-analysis of randomized controlled trials (RCTs) to better assess the effects of intracoronary nicorandil administration on myocardial microcirculation and clinical outcomes in these patients. METHODS The meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. A literature search was performed in the PubMed, Embase, Cochrane Library, and Web of Science databases up to April 2019, with no time or language limitations. Pooled risk ratios (RRs) were calculated to evaluate the treatment effects. RESULTS Seven RCTs involving a total of 562 patients were included. Compared with control, intracoronary nicorandil significantly reduced the incidence of thrombolysis in myocardial infarction (TIMI) grade ≤ 2 (RR 0.349; 95% confidence interval [CI] 0.199-0.611; P < 0.001) and TIMI myocardial perfusion grade ≤ 2 (RR 0.611; 95% CI 0.438-0.852; P = 0.004) and was associated with higher complete ST-segment resolution rates (RR 1.326; 95% CI 1.090-1.614; P = 0.005). However, no significant benefits were observed on clinical outcomes, including death (RR 0.370; 95% CI 0.085-1.618; P = 0.187), recurrent myocardial infarction (RR 0.507; 95% CI 0.156-1.655; P = 0.261), heart failure (RR 0.528; 95% CI 0.224-1.247; P = 0.145), and target lesion/vessel revascularization (RR 1.109; 95% CI 0.553-2.224; P = 0.770). CONCLUSIONS Intracoronary nicorandil can significantly improve myocardial microcirculation in patients with AMI undergoing PPCI, but it failed to offer clinically significant benefits.
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10.
The Efficacy and Safety of Nicorandil for Periprocedural Myocardial Injury in Patients Undergoing PCI: A Meta-Analysis.
Lu, Y, Hu, W, Song, Q, Wang, Q
Journal of interventional cardiology. 2020;:3293587
Abstract
PURPOSE To evaluate the efficacy and safety of nicorandil for periprocedural myocardial injury in patients undergoing PCI through meta-analysis of randomized controlled trials. METHODS We analyzed the clinical data of patients including the incidence of periprocedural myocardial injury (PMI) and major adverse cardiovascular events (MACE) from selected articles. RCTs were retrieved from medical literature databases. RR and 95% confidence intervals (CI) were calculated to compare the endpoints. RESULTS In total, 15 articles (16 trial comparisons) were retrieved which contained 2221 patients. In general, 1130 patients (50.9%) were randomized to the experimental group, whereas 1091 patients (49.1%) were randomized to the control group. The result showed that nicorandil significantly reduced the incidence of PMI and MACE after PCI compared to the control group. CONCLUSIONS Overall, early use of nicorandil in patients undergoing percutaneous coronary intervention (PCI) was associated with a significant reduction of PMI and MACE.