Cognitive behavioral therapy for depression in patients with heart failure: a systematic review and metanalysis of randomized control trials.

Major depression (MD) is prevalent in patients with heart failure (HF) and contributes to increased risk of hospitalization and mortality. The implementation of cognitive behavioral therapy (CBT) has become a key strategy for treating HF patients' depression. We performed a comprehensive literature search for studies that evaluated the efficacy of adjunctive CBT compared to the standard of care (SOC) in HF patients with MD. The primary outcome was the depression scale (post-intervention and by the end of follow-up). The secondary outcomes were the quality of life (QoL), self-care scores, and 6-min walk test distance(6-MW). The standardized mean difference (SMD) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model. A total of 6 RCTs with 489 patients (244 in the CBT group and 245 in the SOC group) were included. As compared to the SOC, CBT was associated with a statistically significant improvement in the post-interventional depression scale (SMD: -0.45, 95%CI: -0.69, -0.21; P < 0.01) and by the end of follow-up (SMD: -0.68, 95%CI: -0.87, -0.49; P < 0.01). Furthermore, CBT significantly improved the QoL (SMD: -0.45, 95%CI: -0.65, -0.24; P < 0.01). However, there were no differences in the self-care scores (SMD: 0.17, 95%CI: -0.08, 0.42; P = 0.18) or in 6-MW (SMD: 0.45, 95%CI: -0.39, 1.28; P = 0.29) between the two groups. According to our meta-analysis of published clinical studies, CBT may be more effective than standard therapy at enhancing depression scores and quality of life. To assess the long-term clinical effects of CBT in heart failure patients, larger and more powerful RCTs are required.

Efficacy of ICD/CRT-D Remote Monitoring in Patients With HFrEF: a Bayesian Meta-analysis of Randomized Controlled Trials.

PURPOSE OF REVIEW: To evaluate remote monitoring using implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) devices as an adjunctive tool to the traditional care of patients with heart failure (HF). RECENT FINDINGS: We included 11 trials encompassing 5965 patients. Absolute risk difference (ARD) with 95% credible interval (CrI) was estimated. Pooled (posterior) risk difference was computed using Bayesian hierarchical methods. The ARD for mortality was centered at - 0.01 (95% CrI: - 0.03; 0.01, Tau: 0.02), with an 82% probability of ARD of ICD/CRT-D remote monitoring with respect to control being less than 0. The ARD for cardiovascular mortality was centered at - 0.03 (95% CrI: - 0.11; 0.05, Tau: 0.10), with an 84% probability of ARD of ICD/CRT-D remote monitoring with respect to control being less than 0. ICD/CRT-D remote monitoring in patients with HF is associated with a higher probability of reduced all-cause and cardiovascular mortality compared with standard care alone.

Valve-in-valve transcatheter aortic valve replacement versus redo surgical valve replacement for degenerated bioprosthetic aortic valve: An updated meta-analysis comparing midterm outcomes.

BACKGROUND: Redo surgical aortic valve replacement (redo SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV TAVR) are the two treatment strategies available for patients with severe symptomatic bioprosthetic aortic valve dysfunction. Herein, we performed a systematic review and meta-analysis comparing both early and mid-term outcomes of ViV TAVR versus redo SAVR in patients with bioprosthetic aortic valve disease. METHODS: PubMed, Cochrane reviews, and Google scholar electronic databases were searched and studies comparing ViV TAVR versus redo SAVR were included. The primary outcome of interest was mid-term (1-5 years) and 1-year all-cause mortality. Secondary outcomes included were 30-day all-cause mortality, myocardial infarction, pacemaker implantation, stroke, acute kidney injury, major or life-threatening bleeding, and postprocedural aortic valve gradients. Pooled risk ratios (RR) with their corresponding 95% confidence intervals (CIs) were calculated for all outcomes using the DerSimonian-Laird random-effects model. RESULTS: Nine observational studies with a total of 2,891 individuals and mean follow-up of 26 months met the inclusion criteria. There is no significant difference in mid-term and 1-year mortality between ViV-TAVR and redo SAVR groups with RR of 1.15 (95% CI 0.99-1.32; p = .06) and 1.06 (95% CI 0.69-1.61; p = .8). 30-day mortality rate was significantly lower in ViV-TAVR group with RR of 0.65 (95% CI 0.45-0.93; p = .02). ViV-TAVR group had lower 30-day bleeding, length of stay, and higher postoperative gradients. CONCLUSION: Our study demonstrates a lower 30-day mortality and similar 1-year and mid-term mortality for ViV TAVR compared to redo SAVR despite a higher baseline risk. Given these findings and the ongoing advances in the transcatheter therapeutics, VIV TAVR should be preferred over redo SAVR particularly in those at intermediate-high surgical risk.

Racial Disparities in Outcomes of Delivery and Cardiac Complications Among Pregnant Women with Congenital Heart Disease.

Advances in cardiology have led to improved survival among patients with congenital heart disease (CHD). Racial disparities in cardiovascular and maternal outcomes are well known and are likely to be more profound among pregnant women with CHD. Using the 2001 to 2018 National Inpatient Sample, we identified all hospitalizations for delivery among women ≥ 18 years of age with CHD. Unadjusted and adjusted between-race differences in adverse maternal cardiovascular, obstetric, and fetal events were assessed using logistic regression models. During the study period, we identified 52,711 hospitalizations for delivery among women with concomitant CHD. Of these, 66%, 11%, and 16% were White, Black, and Hispanic, respectively. Obstetric complications and fetal adverse events were higher among Blacks compared to Whites and Hispanics (44% vs. 33% vs. 37%, p < .001; 36% vs. 28% vs. 30%, p < .001), respectively. No between-race differences were observed in overall cardiovascular adverse events (27% vs. 24% vs. 23%, p < .21). However, heart failure was significantly higher among Black women (3.6% vs. 1.7% vs. 2.2%, p = 0.001). While a lower income quartile was associated with higher rates of adverse outcomes, adjustment for income did not attenuate the adverse impact of race. Black females with CHD diagnoses were more likely to experience adverse obstetric, fetal events, and heart failure compared to White and Hispanic women irrespective of their income status. Further research is needed to identify causes and devise interventions to mitigate racial disparities in the care of pregnant women with CHD.

Sex Differences in the Clinical Outcomes of Patients With Takotsubo Stress Cardiomyopathy: A Meta-Analysis of Observational Studies.

The incidence of takotsubo stress cardiomyopathy (TSCM) in males is low compared with females. Gender-based differences in clinical outcomes of TSCM are not well characterized. The aim of this meta-analysis was to analyze whether gender-based differences are observed in TSCM clinical outcomes. A comprehensive literature search of PubMed, Embase, Cochrane Library database, and Web of Science was performed from inception to June 20, 2022, for studies comparing the clinical outcomes between male and female patients with TSCM. The primary outcome of interest was in-hospital all-cause mortality and cardiogenic shock. The secondary outcomes were cardiovascular mortality, receipt of mechanical ventilation, intra-aortic balloon pump, occurrence of ventricular arrhythmia, and left ventricular thrombus. A random-effects model was used to calculate the risk ratios (RR) and confidence intervals (CI). Heterogenicity was assessed using the Higgins I2 index. Twelve observational studies involving 51,213 patients (4,869 males and 46,344 females) were included in the meta-analysis. Male gender was associated with statistically significant higher in-hospital all-cause mortality compared with females in patients with TSCM (RR 2.17, 95% CI 1.77 to 2.67, p <0.001). The rate of cardiogenic shock was significantly higher in males with TSCM compared with females (RR 1.66, 95% CI 1.29 to 2.12, p <0.001). Our meta-analysis showed a difference in the clinical outcomes of TSCM between men and women. Male gender was associated with a two-fold greater in-hospital all-cause mortality risk compared with female gender. The higher mortality risk associated with male gender deserves further study, particularly whether it represents later recognition of the condition and disparities in treatments.

Impact of anemia on outcomes and resource utilization in patients with myocardial infarction: A national database analysis.

BACKGROUND: Although anemia is common in patients with myocardial infarction (MI), management remains controversial. We quantified the association of anemia with in-hospital outcomes and resource utilization in patients admitted with MI using a large national database. METHODS: All hospitalizations with a primary diagnosis code for acute MI in the National Inpatient Sample (NIS) between 2014 and 2018 were identified. Among these hospitalizations, patients with anemia were identified using a secondary diagnosis code. Data on demographic and clinical variables were collected. Outcomes of interest included in-hospital adverse events, length of stay (LOS), and total cost. Multivariable logistic regression and generalized linear models were used to evaluate the relationship between anemia and outcomes. RESULTS: Among 1,113,181 MI hospitalizations, 254,816 (22.8%) included concomitant anemia. Anemic patients were older and more likely to be women. After adjustment for demographics and comorbidities, anemia was associated with higher mortality (7.1 vs. 4.3%; odds ratio 1.09; 95% confidence interval [CI] 1.07-1.12, p < 0.001). Anemia was also associated with a mean of 2.71 days longer LOS (average marginal effects [AME] 2.71; 95% CI 2.68-2.73, p < 0.05), and $ 9703 mean higher total costs (AME $9703, 95% CI $9577-$9829, p < 0.05). Anemic patients who received blood transfusions had higher mortality as compared with those who did not (8.2% vs. 7.0, p < 0.001). CONCLUSION: In MI patients, anemia was associated with higher in-hospital mortality, adverse events, total cost, and length of stay. Transfusion was associated with increased mortality, and its role in MI requires further research.

Racial Disparities in Outcomes of Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction Secondary to Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a rare cause of ST-segment elevation myocardial infarction (STEMI), predominantly affecting women. Because primary percutaneous coronary intervention (PPCI) is reserved for a select group of patients, vulnerable and minority patients may experience delays in appropriate management and adverse outcomes. We examined the racial differences in the outcomes for patients with SCAD who underwent PPCI for STEMI. Records of patients aged ≥18 years who underwent PPCI for SCAD-related STEMI between 2016 and 2020 were identified from the National Inpatient Sample database. Clinical, socioeconomic, and hospital characteristics were compared between non-White and White patients. Weighted multivariate analysis assessed the association of race with inpatient mortality, length of stay (LOS), and hospitalization costs. The total weighted estimate of patients with SCAD-STEMI who underwent PPCI was 4,945, constituting 25% non-White patients. Non-White patients were younger (56 vs 60.7 years, p <0.001); had a higher prevalence of diabetes, acute renal failure, and obesity; and were more likely to be uninsured and be in the lowest income group. Inpatient mortality (7.7% vs 8.4%, p = 0.74) and hospitalization costs ($34,213 vs $31,858, p = 0.27) were similar for non-White and White patients, and the adjusted analysis did not show any association between the patients' race and inpatient mortality (odds ratio 0.60, 95% confidence interval [CI] 0.32 to 1.13, p = 0.11) or hospitalization costs (ß [ß coefficient]: 215, 95% CI -4,193 to 4,623, p >0.90). Similarly, there was no association between the patients' race and LOS (incident rate ratio 1.20, 95% CI 1.00 to 1.45, p = 0.054). The weighted multivariate analysis showed that age; clinical co-morbidities such as diabetes, acute renal failure, valvular dysfunction, and obesity; low-income status; and hospitalization in the western region were associated with adverse outcomes. In conclusion, our study does not show any differences in inpatient mortality, LOS, and hospitalization costs between non-White and White patients who underwent PPCI for SCAD-related STEMI.

Coronary microvascular dysfunction and cancer therapy-related cardiovascular toxicity.

BACKGROUND: Coronary microvascular dysfunction (CMD) has been implicated as a potential mechanism in the pathophysiology of different clinical presentations, including ischemia and no obstructive coronary artery disease (INOCA), myocardial infarction and nonobstructive coronary arteries (MINOCA), stress cardiomyopathy, heart failure, and myocarditis. There are limited data about the role of CMD in cancer therapy-related cardiovascular toxicities. CASE PRESENTATIONS: Four women with a diagnosis of active cancer receiving treatment who developed subsequent MINOCA or INOCA presented for cardiac catheterization. Upon coronary angiography showing no obstructive coronary arteries, coronary function testing was performed to evaluate for CMD. METHODS: Coronary physiology was assessed measuring non-hyperemic (resting full-cycle ratio [RFR]) and hyperemic (fractional flow reserve [FFR]) indices using a physiologic pressure wire. The wire also measured coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and RFR using thermodilution technology. CMD was confirmed if the CFR was <2.5 and the IMR was >25. RESULTS: Among 4 patients with diagnosis of active cancer presenting with chest pain, there was no evidence of obstructive coronary artery disease, leading to separate diagnoses of INOCA, MINOCA, stress cardiomyopathy, and myocarditis. We found CMD in 2 patients (1 with INOCA and 1 with immune checkpoint inhibitor-related myocarditis). CONCLUSIONS: CMD may play a role in cardiovascular toxicities. Further coronary physiology studies are needed to understand the mechanisms of cancer therapy-related cardiovascular toxicity and CMD, as well as optimal preventive and treatment options.

Bioprosthetic Aortic Valve Thrombosis: Definitions, Clinical Impact, and Management: A State-of-the-Art Review.

Bioprosthetic aortic valve thrombosis is frequently detected after transcatheter and surgical aortic valve replacement due to advances in cardiac computed tomography angiography technology and standardized surveillance protocols in low-surgical-risk transcatheter aortic valve replacement trials. However, evidence is limited concerning whether subclinical leaflet thrombosis leads to clinical adverse events or premature structural valve deterioration. Furthermore, there may be net harm in the form of bleeding from aggressive antithrombotic treatment in patients with subclinical leaflet thrombosis. This review will discuss the incidence, mechanisms, diagnosis, and optimal management of bioprosthetic aortic valve thrombosis after transcatheter aortic valve replacement and bioprosthetic surgical aortic valve replacement.

Acute limb ischemia from embolization of left ventricular pseudoaneurysm thrombus: a rare case report.

Myocardial infarction (MI) can lead to a wide spectrum of mechanical complications. Left ventricular pseudoaneurysm (LVP) is a rare but serious complication of MI. Case presentation: A 69-year-old woman with prior coronary artery bypass grafting and a remote history of inferolateral ST-elevation MI (STEMI) with failure to revascularize the left circumflex artery presented with gangrenous right toes that appeared 2 years after her STEMI. A computed tomography angiogram of the right lower extremity showed arterial occlusion and mild atherosclerotic disease. Echocardiography revealed a pseudoaneurysm with an adherent mural thrombus as the underlying cause of acute limb ischemia. The patient was started on heparin and cardiothoracic surgery was consulted but did not operate as the risk of surgery outweighed the benefit. On hospital day 3, the patient underwent amputation of her gangrenous toes as the tissue was nonviable. The patient remained stable during her hospital stay and was discharged on day 5 on long-term anticoagulation. Clinical discussion: LVPs have a wide spectrum of presentations, from asymptomatic or nonspecific symptoms to thromboembolism with end-organ damage, such as in our case. Therefore, early diagnosis and management are of paramount importance. Our patient's prior coronary artery bypass grafting most likely helped in forming a fibrous pericardium that sealed the pseudoaneurysm and prevented its rupture. Conclusions: STEMI requires close follow-up, especially in cases where revascularization is not achievable, as the risk of mechanical complications and mortality is high. Physicians should have a high suspicion for LVP in patients with prior MI, given its wide spectrum of presentations.

Hypothermia as an Adjunctive Therapy in Cardiogenic Shock: A Systematic Review and Meta-Analysis.

In the setting of out-of-hospital cardiac arrest, therapeutic hypothermia (TH) has been shown to improve clinical outcomes. However, trials showing the advantage of TH did not include patients with cardiogenic shock (CS). We performed a comprehensive literature search for studies that evaluated the efficacy and safety of adjunctive TH compared with the standard of care (SOC) in patients with CS. The primary outcome was the mortality rate (in-hospital, short-, and mid-term). The secondary outcomes were the TH-related complications, duration of Intensive Care Unit (ICU) stay, duration of mechanical ventilation (MV-days), and improvement in cardiac function. Relative risk (RR) or the standardized mean difference (SMD) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model. A total of 7 clinical studies (3 RCTs included), and 712 patients (341 in the TH group and 371 in the SOC group) were included. As compared with the SOC, TH was not associated with a statistically significant improvement in the in-hospital (RR: 0.73%, 95% CI: 0.51-1.03; p = 0.08), short-term (RR: 0.90%, 95% CI: 0.75-1.06; p = 0.21), or mid-term (RR: 0.93%, 95% CI: 0.78-1.10; p = 0.38) mortality rates. Despite the improvement in the cardiac function in the TH group (SMD: 1.08, 95% CI: 0.02-2.1; p = 0.04), the TH strategy did not significantly shorten the MV days, or the ICU stay (p-values >0.05). Finally, there was a trend toward higher risks for infection, major bleeding, and the need for blood transfusion in the TH group. According to our meta-analysis of published clinical studies, TH is not beneficial in patients with CS and has a marginal safety profile. Larger-scale RCTs are needed to further clarify our results.

Long-term Outcomes of Acute Myocardial Infarction in Pre-existing Coronary Artery Ectasia: A Systematic Review and Meta-Analysis.

Coronary artery ectasia is associated with an increased risk of acute myocardial infarction. This meta-analysis evaluates outcomes following acute myocardial infarction in patients with pre-existing coronary artery ectasia. A search strategy was designed to utilize PubMed/Medline, EMBASE, and Google scholar for studies including the outcomes of acute myocardial infarction in patients with coronary artery ectasia from inception to February 10, 2022. We reported effect sizes as odds ratio (OR) with a 95% confidence interval (CI). We used I2 statistics to estimate the extent of unexplained statistical heterogeneity. There were 7 studies comprising 13,499 patients in the final analysis. There was no significant difference between patients with coronary ectasia and patients without coronary ectasia in terms of all-cause mortality (OR 0.95; 95% CI 0.58 to 1.56; P = 0.79; I2 = 0%), major adverse cardiovascular events (MACE; OR 4.04; 95% CI 0.34 to 47.57; P = 0.17; I2 = 95%), myocardial re-infarction (OR 2.13; 95% CI 0.83 to 5.47; P = 0.08; I2 = 59%), target vessel revascularization (OR 1.31; 95% CI 0.69 to 2.48; P = 0.21; I2 = 0%), or requiring mechanical supportive devices (OR 1.32; 95% CI 0.22 to 7.83; P = 0.57; I2 = 56%). Acute myocardial infarction in the presence of coronary artery ectasia is not associated with an increased risk of death, MACE, myocardial infarction, or the need for mechanical circulatory support.

The Evolving Trends in Infective Endocarditis and Determinants of Mortality: a 10-year Experience From a Tertiary Care Epicenter.

The epidemiology of infective endocarditis (IE) continues to evolve in areas affected by the opioid epidemic. Understanding the demographics of the disease allows us to better tailor therapy towards this at-risk population. This was an observational study of adults (age ≥ 18) admitted to the University of Kentucky hospital with IE between January 2009 and December 2018. 1,255 patients were included in the final analysis. The mean age was 42 years, 45% were female and injection drug use was seen in 66% of patients. On multivariable analysis, higher Charlson comorbidity indices, left sided, and multivalve involvement were associated with increased mortality, whereas surgical intervention demonstrated a trend towards lower mortality. Our results highlight the alarming increase in injection drug use related IE and the high mortality rates despite therapeutic advances. Patients with left sided IE, multivalve involvement and a higher Charlson comorbidity index had decreased survival.

Left main coronary artery vasospasm: A case report of misdiagnosed severe coronary artery disease.

Introduction and importance: Left main coronary artery (LMCA) vasospasm is rare and can cause demand-supply mismatch that can mimic coronary artery disease (CAD). This could lead to misdiagnosis and inappropriate referral for surgical intervention. Case presentation: A 55-year-old woman with no cardiac risk factors presented with anginal chest pain. Vital signs were stable and physical exam was unremarkable. Chest x-ray was normal and electrocardiography (ECG) revealed sinus bradycardia with nonspecific ST-segment and T-wave changes in the inferolateral leads present on prior ECGs. Echocardiography revealed a left ventricular ejection fraction of 60-65% without regional wall motion abnormalities and cardiac troponin was within normal limits. Nuclear stress test was unsuccessful due to severe reaction to regadenoson. Subsequent invasive coronary angiography revealed an isolated 70% stenosis of the LMCA. Patient was referred for surgery, however, coronary computed tomography angiography (CCTA) prior to surgery unmasked spasm and prevented unnecessary surgery. Clinical discussion: Coronary spasm is diagnosed clinically based on typical symptoms, transient ECG changes, and a negative stress test with no regional wall motion abnormalities on echocardiography. During episodes of spasm, coronary angiography would reveal an area of stenosis in the affected coronary segment. This could lead to a misdiagnosis of CAD and, in cases of LMCA stenosis, inappropriate referral for surgical intervention. Conclusion: LMCA spasm is rare but can mimic CAD leading to misdiagnosis and unnecessary surgery. Physicians should have a high suspicion for spasm especially in patients with anginal chest pain who lack CAD risk factors. CCTA can unmask spasm and prevent unnecessary interventions.

Delayed acute myocarditis with COVID-19 infection.

Myocardial injury occurs in 20% to 30% of hospitalized patients with COVID-19 infection, and cardiovascular complications contribute to approximately 40% of all COVID-19-related deaths. Most cases of myocarditis related to COVID-19 infection occur in the acute phase of infection and are self-limited. We describe a case of delayed-onset fulminant myocarditis that developed 5 weeks after mild COVID-19 infection leading to cardiogenic shock and the need for mechanical circulatory support. Our case illustrates how myocarditis can occur as a late complication of COVID-19 infection, even in those with a mild initial course.

A systematic review and meta-analysis of the prevalence of transthyretin amyloidosis in heart failure with preserved ejection fraction.

BACKGROUND: Heart failure with preserved ejection fraction is a complex clinical syndrome marked by different phenotypes and related comorbidities. Transthyretin amyloidosis is an underestimated phenotype. We aim to evaluate the prevalence of transthyretin amyloidosis in heart failure with preserved ejection fraction. METHODS: This meta-analysis was conducted according to PRISMA guidelines. A search strategy was designed to utilize PubMed/Medline, EMBASE, and Google scholar to locate studies whose primary objective was to analyze the prevalence of transthyretin amyloidosis in heart failure preserved ejection fraction. RESULTS: Of 271 studies initially identified, 5 studies comprising 670 patients were included in the final analysis. The prevalence of transthyretin amyloidosis was 11%. Patients with transthyretin amyloid cardiomyopathy were more likely to be males (RR 1.38; 95% CI 1.09 to 1.75; P<0.01; I2=37%), and more likely to have low voltage criteria on ECG (RR 2.98; 95% CI 1.03 to 8.58; P=0.04; I2=75%) compared with transthyretin negative group. They also have higher SMD of age (SMD 0.73; 95% CI 0.48 to 0.97; P<0.01; I2=0%), and NT-proBNP (SMD 0.48; 95% CI 0.02 to 0.93; P=0.04; I2=36%) compared with transthyretin negative group. On reported echocardiogram, they have higher SMD of mass index (SMD 0.77; 95% CI 0.27 to 1.27; P<0.01; I2=65%), posterior wall thickness (SMD 0.92; 95% CI 0.62 to 1.21; P<0.01; I2=0%), and septal wall thickness (SMD 1.49; 95% CI 0.65 to 2.32; P<0.01; I2=87%) compared with transthyretin negative group. CONCLUSION: Transthyretin amyloidosis affects 11% of HFpEF patients. Therefore, screening HFpEF patients at risk of cardiac amyloidosis is warranted.

Implementation of Multiple Evidence-Based Heart Failure Therapies.

Despite the advancements in the management of heart failure, acute heart failure is one of the most common causes of mortality and morbidity. In light of the financial burden imposed by heart failure hospitalizations on the health care system, this area remains the focus of research, clinical advances, and policy changes aimed at improving the quality of care and outcomes. Despite practice guidelines, high-quality trial data, and consensus statements, barriers to therapy remain. The barriers related to physician, patient, economic, health care system, and logistical factors prevent widespread adoption of available therapeutics. In this review article, we outline guidelines directed therapies for heart failure, challenges associated with their implementation, and potential solutions to these challenges to help reduce mortality and improve clinical outcomes in this patient population.

Safety and Efficacy of Ultra Short-duration Dual Antiplatelet Therapy After Percutaneous Coronary Interventions: A Meta-analysis of Randomized Controlled Trials.

Dual antiplatelet therapy (DAPT) is required after percutaneous coronary intervention (PCI) to reduce stent thrombosis, but DAPT increases bleeding risks. The optimal duration of DAPT that provides the maximum protective ischemic effect along with the minimum bleeding risk is unclear. This is the first meta-analysis comparing outcomes for 1-month versus longer DAPT strategies following PCI.We searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to October 2021) for randomized controlled trials that compared 1-month duration vs > 1-month duration of DAPT following PCI. We used a random-effects model to calculate risk ratio (RR) with 95% confidence interval (CI). The co-primary outcomes for study selection were all-cause mortality, major bleeding, and stent thrombosis. Secondary outcomes included myocardial infarction (MI), cardiovascular mortality, ischemic stroke and target vessel revascularization. A total of five randomized controlled trials were included [n = 29,355; 1-month DAPT(n = 14,662) vs > 1-month DAPT (n = 14,693)]. There was no statistically significant difference between the two groups in terms of all-cause mortality (RR 0.89; 95% CI 0.78-1.03; P = 0.12) and stent thrombosis (RR 1.07; 95% CI 0.80-1.43; P = 0.65). Similarly, there were no significant differences in MI, cardiovascular mortality, ischemic stroke, and target vessel revascularization. The rate of major bleeding was significantly lower in the group treated with DAPT for 1-month (RR 0.74; 95% CI 0.56-0.99, P = 0.04).There is no difference in all-cause mortality, cardiovascular mortality, MI, stent thrombosis, ischemic stroke, and target vessel revascularization with 1-month of DAPT following PCI with contemporary drug eluting stents compared to longer DAPT duration.

Ischemic and Bleeding Outcomes of Potent P2Y12 Inhibitor Antiplatelet Agents Versus Clopidogrel in Elderly Patients With Acute Coronary Syndrome: A Meta-Analysis of Randomized Trials.

BACKGROUND: The role of P2Y12 inhibition in acute coronary syndrome (ACS) has been well described in literature. However, the agent of choice is less clear among elderly patients (>65 years) who are at increased risk of bleeding. This meta-analysis was designed to investigate the efficacy and safety of potent P2Y12 inhibitors vs. clopidogrel in this population. METHODS AND RESULTS: PubMed, Cochrane Central Register of Clinical Trials, EMBASE, and ClinicalTrial.gov (inception through February 25, 2021) were searched for randomized studies comparing potent oral P2Y12 inhibitors to clopidogrel in elderly population presenting with ACS. Study endpoints included major adverse cardiac events (MACE), major bleeding, all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed and p<0.05 was considered significant. Eight randomized studies with a total 10,081 patients were included in the final analysis. At mean follow up of 26 months, there were no significant differences between potent oral P2Y12 inhibitors and clopidogrel in MACE (HR 0.97, 95% CI [0.82-1.15]; p=0.73), all-cause mortality (HR 0.91, 95% CI [0.75-1.10]; p=1.00), MI (HR 0.95, 95% CI [0.78-1.17]; p=0.64), and stroke (HR 1.24, 95% CI [0.82-1.86]; p=0.31). However, potent oral P2Y12 inhibitors were associated with a reduction in cardiovascular mortality (HR 0.82, 95% CI [0.68-0.98]; p=0.03), and an increase in major bleeding events (HR 1.32, 95% CI [1.09-1.59]; p<0.01). CONCLUSION: In comparison with clopidogrel, the use of potent oral P2Y12 inhibitors in elderly patients with ACS, is associated with a reduction in the risk of cardiovascular mortality with increased risk of bleeding events and no significant change in MACE outcomes.