Early Coronary Angiography and Survival After Out-of-Hospital Cardiac Arrest.

BACKGROUND: Although out-of-hospital cardiac arrest is common because of acute myocardial infarction, it is unknown whether early coronary angiography is associated with improved survival in these patients. METHODS AND RESULTS: Using data from the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 4029 adult patients admitted to 374 hospitals after successful resuscitation from out-of-hospital cardiac arrest because of ventricular fibrillation, pulseless ventricular tachycardia, or unknown shockable rhythm between January 2010 and December 2013. Early coronary angiography (occurring within one calendar day of cardiac arrest) was performed in 1953 (48.5%) patients, of whom 1253 (64.2%) received coronary revascularization. Patients who underwent early coronary angiography were younger (59.9 versus 62.0 years); more likely to be men (78.1% versus 64.3%), have a witnessed arrest (84.6% versus 77.4%), and have ST-segment-elevation myocardial infarction (32.7% versus 7.9%); and less likely to have known cardiovascular disease (22.8% versus 35.0%), diabetes mellitus (11.0% versus 17.0%), and renal disease (1.8% versus 5.8%; P<0.01 for all comparisons). In analysis of 1312 propensity score-matched pairs, early coronary angiography was associated with higher odds of survival to discharge (odds ratio 1.52 [95% confidence interval 1.28-1.80]; P<0.0001) and survival with favorable neurological outcome (odds ratio 1.47 [95% confidence interval 1.25-1.71]; P<0.0001). Further adjustment for coronary revascularization in our models significantly attenuated both odds ratios, suggesting that revascularization was a key mediator of the survival benefit. CONCLUSIONS: Among initial survivors of out-of-hospital cardiac arrest caused by VF or pulseless VT, we found early coronary angiography was associated with higher odds of survival to discharge and favorable neurological outcome.

Trends in the use of percutaneous ventricular assist devices: analysis of national inpatient sample data, 2007 through 2012.

IMPORTANCE: Percutaneous ventricular assist devices (PVADs) provide robust hemodynamic support compared with intra-aortic balloon pumps (IABPs), but clinical use patterns are unknown. OBJECTIVE: To examine contemporary patterns in PVAD use in the United States and compare them with use of IABPs. DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of adults older than 18 years who received a PVAD or IABP while hospitalized in the United States (2007-2012). MAIN OUTCOMES AND MEASURES: Temporal trends in utilization, patient and hospital characteristics, in-hospital mortality, and cost of PVAD use compared with IABP. RESULTS: During 2007 through 2012, utilization of PVADs increased 30-fold (4.6 per million discharges in 2007 to 138 per million discharges in 2012; P for trend < .001) while utilization of IABPs decreased from 1738 per million discharges in 2008 to 1608 per million discharges in 2012 (P for trend = .02). In 2007, an estimated 72 hospitals used PVADs, increasing to 477 in 2011 (P for trend < .001). The number of hospitals with an annual volume of 10 or more PVAD procedures per year increased from 0 in 2007 to 102 in 2011 (21.4% of PVAD-using hospitals; P for trend < .001). Among PVAD recipients, 67.3% had a diagnosis of cardiogenic shock or acute myocardial infarction (AMI). There was a temporal increase in the use of PVADs in older patients and patients with AMI, hypertension, diabetes mellitus, and chronic kidney disease (P for trend < .001 for all). Overall, mortality in PVAD recipients was 28.8%, and mean (SE) hospitalization cost was $85,580 ($4165); both were significantly higher in PVAD recipients with cardiogenic shock (mortality, 47.5%; mean [SE] cost, $113,695 [$6260]; P < .001 for both). The PVAD recipients were less likely than IABP recipients to have cardiogenic shock (34.3% vs 41.2%; P = .001), AMI (48.0% vs 68.6%; P < .001), and undergo coronary artery bypass graft surgery (6.2% vs 43.2%; P < .001), but more likely to undergo percutaneous coronary intervention (70.9% vs 40.4%; P < .001). In propensity-matched analysis, PVADs were associated with higher mortality compared with IABP (odds ratio, 1.23 [95% CI, 1.06-1.43]; P = .007). CONCLUSIONS AND RELEVANCE: There has been a substantial increase in the use of PVADs in recent years with an accompanying decrease in the use of IABPs. Given the high mortality, associated cost, and uncertain evidence for a clear benefit, randomized clinical trials are needed to determine whether use of PVADs leads to improved patient outcomes.

Diet drink consumption and the risk of cardiovascular events: a report from the Women's Health Initiative.

BACKGROUND: Data are limited regarding the influence of diet drink consumption on cardiovascular disease (CVD) outcomes. OBJECTIVE: We aimed to evaluate the relationship between diet drink intake and cardiovascular events. DESIGN: We conducted a retrospective cohort study, utilizing data from the national, multicenter Women's Health Initiative Observational Study (WHI OS), recruiting subjects from 1993 to 1998. PATIENTS: Post-menopausal women with available diet drink intake data, without pre-existing CVD and who survived ≥ 60 days were included in the study. MAIN MEAURES: A composite of incident coronary heart disease, heart failure, myocardial infarction, coronary revascularization procedure, ischemic stroke, peripheral arterial disease and CVD death was used as the primary outcome. CVD death and all-cause mortality were secondary outcomes. Adjusted Cox proportional hazards models were used to compare primary and secondary outcomes across diet drink intake strata. KEY RESULTS: In all, 59,614 women, mean age 62.8 years, were included for analysis. In unadjusted analysis over a follow-up of 8.7 ± 2.7 years, the primary outcome occurred in 8.5 % of the women consuming ≥ 2 diet drinks/day, compared to 6.9 %, 6.8 % and 7.2 % in the 5-7/week, 1-4/week and 0-3/month groups, respectively. After controlling for other CVD risk factors, women who consumed ≥ 2 drinks/day had a higher adjusted risk of CVD events (HR 1.3, 95 % CI 1.1-1.5), CVD mortality (HR 1.5, 95 % CI 1.03-2.3) and overall mortality (HR 1.3, 95 % CI 1.04-1.5) compared to the reference group (0-3 drinks/month). CONCLUSIONS: This analysis demonstrates an association between high diet drink intake and CVD outcomes and mortality in post-menopausal women in the WHI OS.

Outcome comparison of 600 mg versus 300 mg loading dose of clopidogrel for patients with ST-elevation myocardial infarction: a meta-analysis.

BACKGROUND: A 600-mg loading dose (LD) of clopidogrel has been shown to be superior to a 300-mg LD in inhibiting platelet function. However, data for clinical superiority are limited, and there is a paucity of adequately powered randomized trials investigating this issue. This meta-analysis was performed to determine the optimal LD of clopidogrel in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention. METHODS: A meta-analysis of controlled trials and observational studies was performed comparing 600-mg with 300-mg LDs of clopidogrel. The primary efficacy end point was a major adverse cardiac event (MACE), and the primary safety end point was major bleeding. Data were extracted on an intention to treat basis. The X2 test was used to evaluate heterogeneity. A random effects model was used, and odds ratios (OR) were calculated using the Mantel-Haenszel method. RESULTS: Nine studies involving 18 623 patients were included in the efficacy analysis. Mean duration of follow-up was 8 months. Four studies were eligible for the safety analysis. The MACE risk was lower with a 600-mg LD (7.0% [650/9231]) than with a 300-mg LD (9.2% [867/9392]; OR, 0.75; 95% CI, 0.63-0.91). On the other hand, there was no significant difference in the major bleeding events between the 2 groups (2.5% [89/3551] with 600 mg vs 2.3% [63/2796] with 300 mg; OR, 0.84; 95% CI, (0.60-1.16). CONCLUSIONS: In ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention, administration of a 600-mg LD of clopidogrel is associated with a lower risk of MACE than is administration of a 300-mg LD, without increasing the risk of major bleeding.

Single versus double stenting for unprotected left main coronary artery bifurcation lesions: a systematic review and meta-analysis.

OBJECTIVES: We conducted a meta-analysis to assess outcomes for a single-stent (SS) strategy versus a double-stent (DS) strategy in treatment of distal unprotected left main coronary artery (ULMCA) lesions in the drug-eluting stent (DES) era. BACKGROUND: Routine use of DES implantation has contributed to improved outcomes in patients undergoing percutaneous coronary intervention (PCI) for disease involving the ULMCA. However, PCI for ULMCA bifurcation lesions continues to be technically demanding and is an independent predictor of poor outcomes. While a number of stenting techniques have been described, the optimal strategy remains unknown. METHODS: SS treatment was defined as stenting of the main branch alone and DS treatment as stenting of both the main and side branches. Our co-primary endpoints were major adverse cardiovascular events (MACE), and its individual components. RESULTS: We identified 7 observational studies involving 2328 patients. Mean duration of follow-up was 32 months. We adopted the random effect model when computing the combined odds ratio (OR). There was decreased risk of MACE with SS strategy (20.4%) versus DS strategy (32.8%) (OR, 0.51; 95% confidence interval [CI], 0.35-0.73). There was also decreased target vessel/target lesion revascularization (TLR/TVR) with SS strategy (10.1%) versus DS strategy (24.3%) (OR, 0.35; 95% CI, 0.25-0.49). CONCLUSION: Compared to the DS strategy of percutaneous ULMCA bifurcation intervention, an SS approach may be associated with better outcomes.

Meta-analysis of same versus different stent for drug-eluting stent restenosis.

Drug-eluting stent (DES) in-stent restenosis (ISR) can be treated by restenting using the same DES as previously placed (same stent strategy), versus switching to a stent that elutes a different drug (different stent strategy). To compare the efficacy of these strategies, a meta-analysis of controlled trials and observational studies evaluating patients with DES ISR was performed. The primary outcome was target lesion revascularization or target vessel revascularization, and secondary outcomes were major adverse cardiovascular events, death, and myocardial infarction. Pooled odds ratios (ORs) were calculated with the generic inverse variance method using a random-effects model. The chi-square test was used to evaluate heterogeneity. Ten studies (1,680 patients) were included. There was no significant heterogeneity among the studies for any end point. The different stent strategy was found to reduce the odds of target lesion revascularization or target vessel revascularization (OR 0.73, 95% confidence interval [CI] 0.55 to 0.96) and major adverse cardiovascular events (OR 0.72, 95% CI 0.54 to 0.96). There was no difference between the 2 strategies in rates of death (OR 1.03, 95% CI 0.49 to 2.16) or myocardial infarction (OR 0.59, 95% CI 0.24 to 1.41). In conclusion, this study demonstrates that treatment of DES ISR by restenting with a different DES than previously placed may lead to improved outcomes compared with the use of the same DES. Further large-scale trials are needed to confirm this effect.

Radial versus femoral access for primary percutaneous interventions in ST-segment elevation myocardial infarction patients: a meta-analysis of randomized controlled trials.

OBJECTIVES: This study sought to determine the safety and efficacy of radial access compared with femoral access for primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Numerous randomized controlled trials, including several new studies, have compared outcomes of these approaches in the context of primary PCI for STEMI patients with inconclusive results. METHODS: We performed a meta-analysis of randomized controlled trials to compare outcomes in STEMI patients undergoing radial versus femoral access for primary PCI. Primary outcomes were death and major bleeding evaluated at the longest available follow-up. Secondary outcomes included access site bleeding, stroke, and procedure time. Twelve studies (N = 5,055) were included. All trials were conducted in centers experienced with both approaches. RESULTS: Compared with femoral approach, radial approach was associated with decreased risk of mortality (2.7% vs. 4.7%; odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.40 to 0.76; p < 0.001) and decreased risk of major bleeding (1.4% vs. 2.9%; OR: 0.51, 95% CI: 0.31 to 0.85; p = 0.01). Radial access was also associated with reduction in relative risk of access site bleeding (2.1% vs. 5.6%; OR: 0.35, 95% CI: 0.25 to 0.50; p < 0.001). Stroke risk was similar between both approaches (0.5% vs. 0.5%; OR: 1.07, 95% CI: 0.45 to 2.54; p = 0.87). The procedure time was slightly longer in the radial group than in the femoral group (mean difference: 1.52 min; 95% CI: 0.33 to 2.70, p = 0.01). CONCLUSIONS: In STEMI patients undergoing primary PCI, the radial approach is associated with favorable outcomes and should be the preferred approach for experienced radial operators.

Are treatments for vasovagal syncope effective? A meta-analysis.

BACKGROUND: Therapies used to treat vaso-vagal syncope (VVS) recurrence have not been proven effective in single studies. METHODS: Comprehensive search of PubMed, EMBASE and Cochrane Central databases of published trials was done. Randomized or non-randomized studies, comparing the intervention of interest to control group(s), with the endpoint of spontaneous recurrence or syncope on head-up tilt test, were included. Data were extracted on an intention-to-treat basis. Study heterogeneity was analyzed by Cochran's Q statistics. A random-effect analysis was used. RESULTS: α-adrenergic agonists were found effective (n=400, OR 0.19, CI 0.06-0.62, p<0.05) in preventing VVS recurrence. ß-blockers were not found to be effective when only randomized studies comparing ß-blockers to non-pharmacologic agents were assessed (9 studies, n=583, OR 0.48, CI 0.22-1.04, p=0.06). Tilt-training had no effect when only randomized studies were considered (4 studies, n=298, OR 0.47, CI 0.21-1.05, p=0.07). Selective serotonin reuptake inhibitors were found effective (n=131, OR 0.28, CI 0.10-0.74, p<0.05), though the analysis contained only 2 studies. Pacemakers were found effective in preventing syncope recurrence when all studies were analyzed (n=463, OR 0.13, CI 0.05-0.36, p<0.05). However, studies comparing active pacemaker to sensing mode only did not show benefit (3 studies, n=162, OR 0.45, CI 0.09-2.14, p=0.32). CONCLUSIONS: This meta-analysis highlights the totality of evidence for commonly used medications used to treat VVS, and the requirement for larger, double-blind, placebo controlled trials with longer follow-up.