Intravascular imaging-guided vs. angiography-guided percutaneous coronary intervention: A systematic review and meta-analysis of randomized controlled trials in high-risk patients and complex coronary anatomies.

BACKGROUND: Despite a large body of evidence supporting the use of intravascular imaging (IVI) to guide percutaneous coronary intervention (PCI), concerns exist about its universal recommendation. The selective use of IVI to guide PCI of complex lesions and patients is perceived as a rational approach. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs). Embase, PubMed, and Cochrane were systematically searched for RCTs that compared IVI-guided PCI with angiography-guided PCI in high-risk patients and complex coronary anatomies. The primary outcome was major adverse cardiac events (MACE). A random-effects model was used to calculate the risk ratios (RRs) with 95 % confidence intervals (CIs). RESULTS: A total of 15 RCTs with 14,109 patients were included and followed for a weighted mean duration of 15.8 months. IVI-guided PCI was associated with a decrease in the risk of MACE (RR: 0.65; 95 % CI: 0.56-0.77; p < 0.01), target vessel failure (TVF) (RR: 0.66; 95 % CI: 0.52-0.84; p < 0.01), all-cause mortality (RR: 0.71; 95 % CI: 0.55-0.91; p < 0.01), cardiovascular mortality (RR: 0.47; 95 % CI: 0.34-0.65; p < 0.01), stent thrombosis (RR: 0.55; 95 % CI: 0.38-0.79; p < 0.01), myocardial infarction (RR: 0.81; 95 % CI: 0.67-0.98; p = 0.03), and repeated revascularizations (RR: 0.70; 95 % CI: 0.58-0.85; p < 0.01) compared with angiography. There was no significant difference in procedure-related complications (RR: 1.03; 95 % CI: 0.75-1.42; p = 0.84) between groups. CONCLUSIONS: Compared with angiographic guidance alone, IVI-guided PCI of complex lesions and high-risk patients significantly reduced all-cause and cardiovascular mortality, MACE, TVF, stent thrombosis, myocardial infarction, and repeat revascularization.

Torsemide versus Furosemide in the Treatment of Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. / Torsemida em Comparação com Furosemida no Tratamento da Insuficiência Cardíaca: Uma Revisão Sistemática e Metanálise de Ensaios Clínicos Randomizados.

Furosemide is the most used diuretic for volume overload symptoms in patients with heart failure (HF). Recent data suggested that torsemide may be superior to furosemide in this setting. However, whether this translates into better clinical outcomes in this population remains unclear. To assess whether torsemide is superior to furosemide in the setting of HF. We performed a systematic review and meta-analysis of RCTs comparing the efficacy of torsemide versus furosemide in patients with HF. PubMed, Embase, and Web of Science were searched for eligible trials. Outcomes of interest were all-cause hospitalizations, hospitalizations for HF (HHF), hospitalizations for all cardiovascular causes, all-cause mortality, and NYHA class improvement. Echocardiographic parameters were also assessed. We applied a random-effects model to calculate risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) and a 0.05 level of significance. 12 RCTs were included, comprising 4,115 patients. Torsemide significantly reduced HHF (RR 0.60; 95% CI, 0.43-0.83; p=0.002; I2=0%), hospitalization for cardiovascular causes (RR 0.72; 95% CI, 0.60-0.88; p=0.0009; I2=0%), and improved LVEF (MD 4.51%; 95% CI, 2.94 to 6.07; p<0.0001; I2=0%) compared with furosemide. There was no significant difference in all-cause hospitalizations (RR 0.93; 95% CI, 0.86-1.00; p=0.04; I2=0%), all-cause mortality (RR 0.98; 95% CI, 0.87-1.10; p=0.73; I2=0%), NYHA class improvement (RR 1.25; 95% CI, 0.92-1.68; p=0.15; I2=0%), or NYHA class change (MD -0.04; 95% CI, -0.24 to 0.16; p=0.70; I2=15%) between groups. Torsemide significantly reduced hospitalizations for HF and cardiovascular causes, also improving LVEF.

A furosemida é o diurético mais utilizado para o tratamento de sintomas de sobrecarga de volume em pacientes com insuficiência cardíaca. Dados recentes sugerem que a torsemida pode ser superior à furosemida neste contexto. No entanto, ainda não é claro se isso se traduz em melhores resultados clínicos nesta população. Avaliar se a torsemida é superior à furosemida no contexto da insuficiência cardíaca. Realizamos uma revisão sistemática e metanálise de estudos clínicos randomizados (ECRs) comparando a eficácia da torsemida em comparação com a furosemida em pacientes com insuficiência cardíaca. PubMed, Embase e Web of Science foram as bases de dados pesquisadas em busca de estudos elegíveis. Os desfechos de interesse foram internações por todas as causas, internações por insuficiência cardíaca (IIC), internações por todas as causas cardiovasculares, mortalidade por todas as causas, e melhoria de classe da NYHA. Parâmetros ecocardiográficos também foram avaliados. Foi aplicado um modelo de efeitos aleatórios para calcular as razões de risco (RR) e as diferenças médias (DM) com intervalos de confiança (IC) de 95% e nível de significância de 0,05. Foram incluídos 12 ECRs, envolvendo 4.115 pacientes. A torsemida reduziu significativamente a IIC (RR de 0,60; IC de 95%, 0,43-0,83; p=0,002; I2=0%), internação por causas cardiovasculares (RR de 0,72; IC de 95%, 0,60-0,88; p=0,0009; I2=0%), e melhora da fração de ejeção do ventrículo esquerdo (FEVE) (DM de 4,51%; IC de 95%, 2,94 a 6,07; p<0,0001; I2=0%) em comparação com a furosemida. Não houve diferença significativa no número de internações por todas as causas (RR de 0,93; IC de 95%, 0,86-1,00; p=0,04; I2=0%), mortalidade por todas as causas (RR de 0,98; IC de 95%, 0,87-1,10; p=0,73; I2=0%), melhora da classe NYHA (RR de 1,25; IC de 95%, 0,92-1,68; p=0,15; I2=0%), ou mudança de classe NYHA (DM de -0,04; IC de 95%, -0,24 a 0,16; p=0,70; I2=15%) entre os grupos. A torsemida reduziu significativamente as internações por insuficiência cardíaca e causas cardiovasculares, melhorando também a FEVE.

Avaliação prognóstica de parâmetros ecocardiográficos em pacientes com Doença de Chagas: uma revisão sistemática e metanálise / Prognostic evaluation of echocardiographic parameters in patients with Chagas disease: a systematic review and meta-analysis

CONTEXTO: A doença de Chagas continua sendo uma das principais causas não isquêmicas de cardiomiopatia na América Latina. No entanto, nossa compreensão dos parâmetros ecocardiográficos prognósticos além da fração de ejeção do ventrículo esquerdo (FEVE) permanece limitada. Objetivo: Conduzir uma revisão sistemática e metanálise para avaliar a relação entre o strain longitudinal global do ventrículo esquerdo (GLS-VE), o diâmetro diastólico final do ventrículo esquerdo (DDFVE) e a FEVE com o risco de mortalidade por todas as causas, transplante cardíaco ou necessidade de dispositivo de assistência ventricular mecânica. MÉTODOS: Realizamos uma busca sistemática nas bases de dados Elsevier, PubMed e Cochrane por estudos que avaliassem GLS-VE, DDFVE e FEVE em pacientes com doença de Chagas, abrangendo tanto as fases indeterminada quanto de cardiomiopatia. A análise estatística foi realizada utilizando o RevMan 5.1.7, e a heterogeneidade foi avaliada usando estatísticas I². Calculamos razões de risco (HR) combinadas com intervalos de confiança (IC) de 95% sob um modelo de efeitos aleatórios. Também realizamos uma análise de subgrupos de análises multivariáveis para minimizar o efeito de variáveis de confusão. RESULTADOS: Incluímos 1.277 pacientes de 10 estudos observacionais, com idade média variando de 53 a 66 anos, sendo 60,3% do sexo masculino. Desses pacientes, 1.138 (89%) apresentavam cardiomiopatia chagásica, enquanto 139 estavam na fase indeterminada. A FEVE média variou de 26% a 52%. A redução do GLS-VE (HR 1,14; IC 95% 1,01-1,29; p= 0,04; Figura 1A) e o aumento do DDFVE (HR 1,07; IC 95% 1,02-1,12; p< 0,0001; Figura 1B) foram associados a maior risco de mortalidade por todas as causas, transplante cardíaco ou necessidade de dispositivo de assistência ventricular mecânica. Em contrapartida, maiores índices de FEVE foram associados a menor risco desse desfecho composto (HR 0,93; IC 95% 0,90-0,96; p= 0,002), o que permaneceu estatisticamente significativo após análise de subgrupos com apenas resultados ajustados por multivariáveis (HR 0,95; IC 95% 0,91- 0,99; p= 0,001; Figura 1C). CONCLUSÃO: Nesta revisão sistemática e metanálise de pacientes com doença de Chagas, a redução do GLS-VE e o aumento do DDFVE foram associados a maior risco de mortalidade por todas as causas, transplante cardíaco ou necessidade de dispositivo de assistência ventricular mecânica, enquanto o aumento da FEVE foi fator protetor prognóstico independente para esse desfecho.

Venoarterial extracorporeal membrane oxygenation versus impella for cardiogenic shock in acute myocardial infarction: a systematic review and meta-analysis

BACKGROUND: Acute myocardial infarction (AMI) is an important cause of cardiogenic shock (CS). There is lack of evidence regarding the safety and efficacy of venoarterial extracorporeal membrane oxygenation (VA-ECMO) compared with Impella in this population. METHODS: We systematically searched PubMed, EMBASE, and Cochrane Library for studies comparing VA-ECMO with Impella in patients with CS related to AMI. The systematic review and meta-analysis followed Cochrane recommendations and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We used R version 4.3.1 for all statistical analyses. Odds ratios (OR) and 95% confidence intervals (CI) were pooled with a random-effects model. RESULTS: We included seven observational studies with 15.903 patients, of whom 12.943 (81.3%) were treated with Impella. There was no significant difference between groups regarding in-hospital mortality (OR 0.79; 95% CI 0.37-1.69; p=0.54; Figure 1A), ischemic stroke (OR 0.69; 95% CI 0.14-3.35; p=0.64; Figure 1B), acute kidney injury (OR 1.22; 95% CI 0.55-2.70; p=0.62), renal replacement therapy or dialysis (OR 1.02; 95% CI 0.33-3.19; p=0.97; Figure 1C), and blood transfusion (OR 0.52; 95% CI 0.16-1.72; p=0.28). CONCLUSION: In this meta-analysis, there was no significant difference between VA-ECMO and Impella among patients with CS and AMI for the outcomes of in-hospital mortality, ischemic stroke, acute kidney injury, renal replacement therapy, or blood transfusion.

Long-term impact of home-based monitoring after an admission for acute decompensated heart failure: a systematic review and meta-analysis of randomised controlled trials.

Background: Patients with heart failure have high rehospitalisation rates and poor cardiovascular outcomes. Home-based monitoring (HBM) has emerged with promising results in different settings. However, its long-term effects on patients recently admitted for acute decompensated heart failure (ADHF) remain uncertain. Methods: We systematically searched PubMed, Embase, and Cochrane Library for randomised controlled trials (RCTs) comparing HBM with usual care (UC) that were published between database inception and June 24, 2023. We included studies with patients admitted for ADHF in the previous 6 months and with a minimum follow-up of 6 months. We excluded studies with patients hospitalised for reasons other than ADHF and studies with disproportional education interventions between arms. Statistical analyses were performed using R software version 4.3.2. We pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) for categorical and continuous outcomes, respectively. Cochrane Collaboration's tool for assessing risk of bias in RCTs (RoB 2) was used to assess study quality. Publication bias was assessed via funnel plots and Egger's test, and heterogeneity was assessed through I2 statistics and sensitivity analysis. The protocol for this systematic review and meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023465359). Findings: We included 16 RCTs comprising 4629 patients, of whom 2393 (51.7%) were randomised to HBM and 3150 (68%) were men. Follow-up ranged from six to fifteen months. As compared with UC, HBM significantly reduced all-cause mortality (RR 0.75; 95% CI 0.61, 0.91; p = 0.005), all-cause hospitalisations (RR 0.82; 95% CI 0.70, 0.97; p = 0.018), cardiovascular (CV) mortality (RR 0.53; 95% CI 0.36, 0.79; p = 0.002), hospitalisations for heart failure (RR 0.75; 95% CI 0.62, 0.91; p = 0.004), and CV hospitalisations (RR 0.72; 95% CI 0.55, 0.95; p = 0.018). There were no significant differences in length of hospital stay (MD 0.97 days; 95% CI -0.90, 2.84; p = 0.308). Interpretation: In patients recently admitted with ADHF, HBM significantly reduces long-term all-cause mortality and hospitalisations, CV mortality and hospitalisations, and hospitalisations for heart failure, as compared with UC. This supports the implementation of HBM as a standard practice to optimise patient outcomes following admissions for ADHF. However, future studies are warranted to evaluate the efficacy and safety of implementing HBM in the real-world setting. Funding: None.

Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation on chronic hemodialysis: a meta-analysis of randomized controlled trials.

PURPOSE: Patients with atrial fibrillation (AF) and end-stage renal disease on chronic hemodialysis are at risk for thromboembolic and bleeding events. We aimed to perform a meta-analysis to evaluate the safety and efficacy of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in this population. METHODS: We systematically searched PubMed, Excerpta Medica Database (EMBASE) and Cochrane Library for randomized controlled trials (RCTs) comparing DOACs with VKAs in patients with AF on chronic hemodialysis from inception to February 2023 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes were reported using risk ratios (RRs) with 95% confidence intervals (CIs). Statistical analyses were performed using R version 4.2.2. RESULTS: We selected three RCTs including 341 patients, of whom 176 (51.6%) were randomized to DOACs. Follow-up ranged from 174 days to 3.38 years. There was no significant difference between groups in terms of cardiovascular mortality (RR 1.34; 95% CI 0.69-2.60; p = 0.39), all-cause mortality (RR 0.96; 95% CI 0.72-1.27; p = 0.77), ischemic/uncertain type of stroke or transient ischemic attack (RR 0.50; 95% CI 0.19-1.35; p = 0.17), or major or life-threatening bleeding (RR 0.70; 95% CI 0.39-1.25; p = 0.22). CONCLUSION: In this meta-analysis of three RCTs, no significant difference was observed between DOACs and VKAs in cardiovascular mortality, all-cause mortality, ischemic/uncertain type of stroke or transient ischemic attack, or major or life-threatening bleeding in patients with AF on chronic hemodialysis.

Torsemida em Comparação com Furosemida no Tratamento da Insuficiência Cardíaca: Uma Revisão Sistemática e Metanálise de Ensaios Clínicos Randomizados / Torsemide versus Furosemide in the Treatment of Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Resumo A furosemida é o diurético mais utilizado para o tratamento de sintomas de sobrecarga de volume em pacientes com insuficiência cardíaca. Dados recentes sugerem que a torsemida pode ser superior à furosemida neste contexto. No entanto, ainda não é claro se isso se traduz em melhores resultados clínicos nesta população. Avaliar se a torsemida é superior à furosemida no contexto da insuficiência cardíaca. Realizamos uma revisão sistemática e metanálise de estudos clínicos randomizados (ECRs) comparando a eficácia da torsemida em comparação com a furosemida em pacientes com insuficiência cardíaca. PubMed, Embase e Web of Science foram as bases de dados pesquisadas em busca de estudos elegíveis. Os desfechos de interesse foram internações por todas as causas, internações por insuficiência cardíaca (IIC), internações por todas as causas cardiovasculares, mortalidade por todas as causas, e melhoria de classe da NYHA. Parâmetros ecocardiográficos também foram avaliados. Foi aplicado um modelo de efeitos aleatórios para calcular as razões de risco (RR) e as diferenças médias (DM) com intervalos de confiança (IC) de 95% e nível de significância de 0,05. Foram incluídos 12 ECRs, envolvendo 4.115 pacientes. A torsemida reduziu significativamente a IIC (RR de 0,60; IC de 95%, 0,43-0,83; p=0,002; I2=0%), internação por causas cardiovasculares (RR de 0,72; IC de 95%, 0,60-0,88; p=0,0009; I2=0%), e melhora da fração de ejeção do ventrículo esquerdo (FEVE) (DM de 4,51%; IC de 95%, 2,94 a 6,07; p<0,0001; I2=0%) em comparação com a furosemida. Não houve diferença significativa no número de internações por todas as causas (RR de 0,93; IC de 95%, 0,86-1,00; p=0,04; I2=0%), mortalidade por todas as causas (RR de 0,98; IC de 95%, 0,87-1,10; p=0,73; I2=0%), melhora da classe NYHA (RR de 1,25; IC de 95%, 0,92-1,68; p=0,15; I2=0%), ou mudança de classe NYHA (DM de -0,04; IC de 95%, -0,24 a 0,16; p=0,70; I2=15%) entre os grupos. A torsemida reduziu significativamente as internações por insuficiência cardíaca e causas cardiovasculares, melhorando também a FEVE.

Abstract Furosemide is the most used diuretic for volume overload symptoms in patients with heart failure (HF). Recent data suggested that torsemide may be superior to furosemide in this setting. However, whether this translates into better clinical outcomes in this population remains unclear. To assess whether torsemide is superior to furosemide in the setting of HF. We performed a systematic review and meta-analysis of RCTs comparing the efficacy of torsemide versus furosemide in patients with HF. PubMed, Embase, and Web of Science were searched for eligible trials. Outcomes of interest were all-cause hospitalizations, hospitalizations for HF (HHF), hospitalizations for all cardiovascular causes, all-cause mortality, and NYHA class improvement. Echocardiographic parameters were also assessed. We applied a random-effects model to calculate risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) and a 0.05 level of significance. 12 RCTs were included, comprising 4,115 patients. Torsemide significantly reduced HHF (RR 0.60; 95% CI, 0.43-0.83; p=0.002; I2=0%), hospitalization for cardiovascular causes (RR 0.72; 95% CI, 0.60-0.88; p=0.0009; I2=0%), and improved LVEF (MD 4.51%; 95% CI, 2.94 to 6.07; p<0.0001; I2=0%) compared with furosemide. There was no significant difference in all-cause hospitalizations (RR 0.93; 95% CI, 0.86-1.00; p=0.04; I2=0%), all-cause mortality (RR 0.98; 95% CI, 0.87-1.10; p=0.73; I2=0%), NYHA class improvement (RR 1.25; 95% CI, 0.92-1.68; p=0.15; I2=0%), or NYHA class change (MD -0.04; 95% CI, -0.24 to 0.16; p=0.70; I2=15%) between groups. Torsemide significantly reduced hospitalizations for HF and cardiovascular causes, also improving LVEF.

Efficacy of anti-amyloid-ß monoclonal antibody therapy in early Alzheimer's disease: a systematic review and meta-analysis.

BACKGROUND: Studies targeting amyloid-ß in patients with Alzheimer's disease (AD) have conflicting results and early initiation of therapy may yield better outcomes. METHODS: We systematically searched PubMed, Embase, Cochrane Library, and Clinicaltrials.gov for randomized trials comparing monoclonal antibodies (mAbs) with placebo in MCI or mild dementia due to AD. RESULTS: Nineteen studies comprising 15,275 patients were included. In patients with early AD, mAbs reduced the rate of decline, in both the Clinical Dementia Rating Scale, the sum of boxes (CDR-SB; MD -0.30; 95% CI -0.42,-0.19; p < 0.01), and the Alzheimer's Disease Assessment Scale, cognitive subscore (ADAS-cog; SMD -0.80; 95% CI -10.25,-0.35; p < 0.01). The results were similar between clinical stages for CDR-SB (MCI, MD -0.19; 95% CI -0.35,-0.03; p = 0.02; mild dementia, MD -0.45; 95% CI -0.65,-0.25; p < 0.01; subgroup differences, p = 0.13), as well as for ADAS-Cog (MCI, SMD -0.83; 95% CI -1.49,-0.17; p = 0.01; mild dementia, SMD -0.69; 95% CI -1.32 to -0.05; p = 0.03; subgroup differences, p = 0.47). The risk of amyloid-related imaging abnormalities (ARIA) was significantly higher in patients taking mAbs, including ARIA-edema (RR 7.7; 95% CI 4.60 to 13.00; p < 0.01), ARIA-hemorrhage (RR 1.8; 95% CI 1.22 to 2.59; p < 0.01), and symptomatic or serious ARIA (RR 14.1; 95% CI 7.30 to 27.14; p < 0.01). CONCLUSION: Anti-amyloid-ß mAbs attenuate cognitive and functional decline compared with placebo in early AD; whether the magnitude of this effect is clinically important remains uncertain, especially relative to the safety profile of these medications. Starting immunotherapy in patients with MCI was not significantly different than starting in the mild dementia stage. PROSPERO REGISTRY: CRD42023430698.