Systematic review and meta-analysis of early aortic valve replacement versus conservative therapy in patients with asymptomatic aortic valve stenosis with preserved left ventricle systolic function.

BACKGROUND: A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function. METHODS AND RESULTS: We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I2=31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I2=84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding. CONCLUSION: We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations. PROSPERO REGISTRATION NUMBER: CRD42022306132.

Meta-Analysis Comparing Fractional Flow Reserve and Angiography-Guided Complete Revascularization of Nonculprit Artery for ST-Elevation Myocardial Infarction.

This study aimed to compare complete revascularization (CR) guided by angiography with a fractional flow reserve (FFR)-guided strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD). CR is preferred to culprit-only revascularization for patients with STEMI and MVD. However, whether FFR-guided CR is superior to angiography-guided CR is unclear in patients presenting with STEMI who have MVD. Randomized controlled trials comparing CR with an FFR- or angiography-guided strategy to culprit-only revascularization in patients with STEMI and MVD were systematically identified. A random-effects network meta-analysis was performed comparing clinical outcomes in the 3 arms. A total of 13 studies with a total of 8,927 patients were included in our analysis. Compared with culprit-only revascularization, angiography-guided CR was associated with a significantly decreased risk of myocardial infarction (MI) (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.37 to 0.82), all-cause death (HR 0.69, 95% CI 0.49 to 0.97), and cardiovascular death (HR 0.54, 95% CI 0.34 to 0.85) but FFR-guided CR was not (MI: HR 0.77, 95% CI 0.53 to 1.12; cardiovascular death: HR 0.89, 95% CI 0.64 to 1.24; all-cause death: HR 0.93, 95% CI 0.72 to 1.18). The network meta-analysis comparison of angiography- versus FFR-guided CR showed an HR of 0.75 (95% CI 0.50 to 1.11) for all-cause death and an HR of 0.71 (95% CI 0.54 to 1.17) for MI. In conclusion, for patients with MVD presenting with STEMI, angiography-guided CR may provide additional benefits compared with FFR-guided CR.

Trans-radial approach versus trans-femoral approach in patients with acute coronary syndrome undergoing percutaneous coronary intervention: An updated meta-analysis of randomized controlled trials.

INTRODUCTION: Trans-radial approach (TRA) is recommended over trans-femoral approach (TFA) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). We intended to study the effect of access on all-cause mortality. METHODS AND RESULTS: We searched PubMed and EMBASE for randomized studies on patients with ACS undergoing PCI. The primary outcome was all-cause mortality at 30-days. The secondary outcomes included in-hospital mortality, major adverse cardiac or cerebrovascular event (MACE) as defined by the study, net adverse clinical event (NACE), non-fatal myocardial infarction, non-fatal stroke, stent thrombosis, study-defined major bleeding, and minor bleeding, vascular complications, hematoma, pseudoaneurysm, non-access site bleeding, need for transfusion, access site cross-over, contrast volume, procedure duration, and hospital stay duration. We studied 20,122 ACS patients, including 10,037 and 10,085 patients undergoing trans-radial and trans-femoral approaches, respectively. We found mortality benefit in patients with ACS for the trans-radial approach [(1.7% vs. 2.3%; RR: 0.75; 95% CI: 0.62-0.91; P = 0.004; I2 = 0%). Out of 10,465 patients with STEMI, 5,189 patients had TRA and 5,276 had TFA procedures. A similar benefit was observed in patients with STEMI alone [(2.3% vs. 3.3%; RR: 0.71; 95% CI: 0.56-0.90; P = 0.004; I2 = 0%). We observed reduced MACE, NACE, major bleeding, vascular complications, and pseudoaneurysms. No difference in re-infarction, stroke, and serious bleeding requiring blood transfusions were noted. We noticed a small decrease in contrast volume(ml) {mean difference (95% CI): -4.6 [-8.5 to -0.7]}, small but significantly increase in procedural time {mean difference (95% CI) 1.2 [0.1 to 2.3]}and fluoroscopy time {mean difference (95% CI) 0.8 [0.3 to1.4] min} in the trans-radial group. CONCLUSION: TRA has significantly reduced 30-day all-cause mortality among patients undergoing PCI for ACS. TRA should be the preferred vascular access in patients with ACS.