Cardiac rehabilitation for participants with implantable cardiac devices: A systematic review and meta-analysis.

Aim: The aim is to discuss efficacy and safety of exercise-based cardiac rehabilitation (CR) programmes in participants with implantable cardiac devices compared with usual care. Methods: MEDLINE, EMBASE and Cochrane databases were searched from inspection till July 15, 2022. Randomized controlled trials were included if they enrolled adult participants with implantable cardiac devices and tested exercise-based CR interventions in comparison with any control. Risk of bias was assessed, and endpoints data were pooled using random-effects model. Results: Sixteen randomized trials enrolling 2053 participants were included. Study interventions differed between studies in terms of programme components, setting, exercise intensity, and follow-up. All studies included physical exercise component. In both implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy (CRT) groups, exercise training in CR programmes improved peak oxygen uptake (VO2) [(mean difference (MD) 2.08 ml/kg/min; 95 % CI: 1.44-2.728, p < 0.0001; I2 = 99 %) and (MD 2.24 ml/kg/min; 95 % CI: 1.43-3.04, p < 0.0001; I2 = 96 %), respectively] and 6-min walk test in ICD group (MD 41.51 m; 95 % CI: 15.19-67.82 m, p = 0.002; I2 = 95 %) compared with usual care. In CRT group, there was no statistically significant improvement in left ventricular ejection fraction change between comparison groups. The results were consistent in subgroup analysis according to high or low-to-moderate exercise intensity for change in peak VO2 and ejection fraction in CRT group. There was no difference in number of ICD shocks between the comparators. Conclusion: Exercise-based CR programmes appear to be safe when enrolling participants with implantable cardiac devices and leading to favourable functional outcomes.

Myocardial Infarction in Chronic Myeloid Leukemia: Results from Nationwide Readmission Database.

Background and Objective Chronic myeloid leukemia (CML) is a hematological malignancy with an excellent prognostic outcome. After advancements in CML treatment and the introduction of different tyrosine kinase inhibitors (TKI), the life expectancy of CML patients has become equivalent to that of the general population. As a result, coronary artery disease is anticipated to be the leading cause of death among CML patients. Moreover, TKI use is associated with a risk of endothelial dysfunction, thrombosis, and cardiovascular events, including myocardial infarction. In this study, we compare the outcomes of percutaneous coronary intervention (PCI) in patients with CML to their matched non-CML counterparts. and compare the events reported with different TKI. Method The Nationwide Readmission Database (NRD) was searched from January 2016 to December 2020. for the study population. Adults of age ≥ 18 years with or without CML hospitalized for with a primary diagnosis of acute myocardial infarction, ST-segment elevation myocardial infarction (STEMI), and non-ST-segment elevation myocardial infarction (NSTEMI) and underwent PCI were included. The patients were identified using ICD-10 codes. The baseline characteristics and outcomes of the CML and non-CML patients who underwent PCI were compared. The primary outcomes were in-hospital mortality and 30-day readmission rates. The secondary outcomes were the PCI complications rates. Data regarding TKI reports of STEMI and acute coronary syndrome were obtained from The FDA Adverse Event Reporting System (FARES). Results Out of 2,727,619 patients with myocardial infarction, 2,124 CML patients were identified. A total of 888 CML patients underwent PCI. The mean age was 68.34 ± 11.14, with 62.46 % above 65 years. The analysis showed no significant difference between CML and non-CML patients after PCI for death (OR? 0.93 (95% CI 0.49-1.80), P=0.527) and 30-day readmission (OR? 1.41 (95% CI 0.99-2.01), P=0.056) rates. CML patients were significantly older (mean age 68.34 ± 11.14 versus 64.40 ± 12.61, p < 0.001) than non-CML patients without a difference in sex distribution. Hypertension (85.45% versus 78.64%), diabetes (45.48% versus 37.29), stroke (11.84% versus 7.78) at baseline were significantly higher in CML group. Prior myocardial infarction events (20.51% versus 15.17%) and prior PCI procedure (24.47% versus 16.89%) were significantly higher in CML group. CML had a significantly longer hospital stay (4.66 ± 4.40 versus 3.75 ± 4.62 days, p = 0.001). The primary outcomes did not differ between the comparison groups. Conclusion This analysis showed no statistically significant difference in mortality, 30-day readmission, and complication rates post PCI between CML and non-CML patients. However, interestingly, CML patients may experience lower coronary artery dissection and ischemic stroke rates than those without CML diagnosis.

COVID-19-associated hypertriglyceridemia and impact of treatment.

Background: Coronavirus disease 2019 (COVID-19) associated hypertriglyceridemia was observed among patients admitted to intensive care units (ICU) in Qatar. This study aimed to describe COVID-19-associated-hypertriglyceridemia in ICU patients and the impact of treating hypertriglyceridemia on clinical outcomes. Methods: A retrospective observational cohort study of adult patients who were admitted to the ICU with a confirmed diagnosis of COVID-19 pneumonia according to the World Health Organization criteria. Hypertriglyceridemia was defined as triglyceride level of 1.7 mmol/L (≥150 mg/dL) and severe hypertriglyceridemia as fasting TG of ≥5.6 mmol/L (≥500 mg/dL). Results: Of 1,234 enrolled patients, 1,016 (82.3%) had hypertriglyceridemia. Median age was 50 years and 87.9% were males. Patients with hypertriglyceridemia showed significantly longer time to COVID-19 recovery, ICU and hospital stay, and time to death (29.3 vs. 16.9 days) without a difference in mortality between groups. Of patients with hypertriglyceridemia, 343 (33.8%) received treatment (i.e., fibrate and/or omega-3). Patients in treatment group showed longer time to COVID-19 recovery and hospital stay with no difference in death rates in comparison with those in no-treatment group. Relatively older patients were less likely to experience hypertriglyceridemia (odd ratio (OR) 0.976; 95% CI: 0.956, 0.995) or to receive treatment (OR 0.977; 95% CI: 0.960, 0.994). Whereas patients who received tocilizumab were more likely to experience high TG level (OR 3.508; 95% CI: 2.046, 6.015) and to receive treatment for it (OR 2.528; 95% CI: 1.628, 3.926). Conclusion: Hypertriglyceridemia associated with COVID-19 did not increase death rate, but prolonged time to death and length of stay. Treating hypertriglyceridemia did not translate into improvement in clinical outcomes including mortality.

Cost­effectiveness of add­on dapagliflozin for heart failure with reduced ejection fraction patients without diabetes.

AIM: To evaluate the cost-effectiveness of dapagliflozin added to standard of care (SoC) versus SoC in heart failure with reduced ejection fraction (HFrEF) and without type 2 diabetes mellitus (T2DM) patients from the Qatari healthcare perspective. MATERIALS AND METHODS: A lifetime Markov model was developed to evaluate the cost-effectiveness of adding dapagliflozin to SoC based on the findings of Petrie et al. 2020, which were based on the DAPA-HF trial. The model was constructed based on four health states: "alive with no event", "urgent visit for heart failure", "hospitalization for heart failure", and "dead". The model considered 1,000 hypothetical HFrEF and without T2DM patients using 3-month cycles over a lifetime horizon. The outcome of interest was the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year gained (QALY) and years of life lived (YLL). Utility and cost data were obtained from published sources. A scenario analysis was performed to replace the transition probabilities of events in people without T2DM with the transition probabilities of events irrespective of T2DM status, based on findings of the DAPA-HF trial. Sensitivity analyses were conducted to confirm the robustness of the conclusion. RESULTS: Adding dapagliflozin to SoC was estimated to dominate SoC alone, resulting in 0.6 QALY and 0.8 YLL, at a cost saving of QAR771 (USD211) per person compared with SoC alone, with total healthcare costs of QAR42,413 (USD 11,620) versus 43,184 (USD11,831) per person, respectively. When replacing the transition probabilities of events in people without T2DM with the transition probabilities of events in people irrespective of T2DM status, dapagliflozin was cost-effective at ICER of QAR5,212 (USD1,428) per QALY gained and QAR3,880 (USD1,063) per YLL. In the probabilistic sensitivity analysis, dapagliflozin combined with SoC was cost saving in over 49% of the cases and cost-effective in over 43% of the simulated cases against QALYs gained and YLL. LIMITATIONS: Data from clinical trials were used instead of local data, which may limit the local relevance. However, evidence from the local Qatari population is lacking. Also, indirect costs were not included due to a paucity of available data. CONCLUSIONS: Adding dapagliflozin to SoC is likely to be a cost-saving therapy for patients with HFrEF and without T2DM in Qatar.

Heart failure with reduced ejection fraction is a type of heart failure characterized by left ventricular ejection fraction of 40% or less. Dapagliflozin is a novel therapy for this condition, which was initially designed to treat type 2 diabetes mellitus. It is unclear whether dapagliflozin is a cost-effective option for patients with heart failure with reduced ejection fraction and without type 2 diabetes. A lifetime Markov model was developed to evaluate the cost-effectiveness of adding dapagliflozin to standard of care from the Qatari healthcare perspective. Model results suggest that adding dapagliflozin to standard of care dominated standard of care alone, resulting in a gain of 0.8 years of life lived, a gain of 0.6 quality-adjusted life-years, and a cost saving of 211 United States dollars per person.

Extracorporeal Membrane Oxygenation Pathway for Management of Refractory Cardiac Arrest: A Retrospective Study from A National Center of Extracorporeal Cardiopulmonary Resuscitation.

BACKGROUND: Cardiac arrest remains a critical condition with high mortality and catastrophic neurological impact. Extracorporeal cardiopulmonary resuscitation (ECPR) has been introduced as an adjunct in cardiopulmonary resuscitation modalities. However, survival with good neurological outcomes remains a major concern. This study aims to explore our early experience with ECPR and identify the factors associated with survival in patients presenting with refractory cardiac arrest. METHODS: A retrospective cohort study analyzing six-year data from a tertiary center, the country reference for ECPR. SETTING: A national center of ECPR. PARTICIPANTS: Adult patients who experienced witnessed refractory cardiopulmonary arrest and were supported by ECPR. INTERVENTIONS: ECPR for eligible patients as per local service protocol. RESULTS: Data from 87 patients were analyzed; of this cohort, 62/87 patients presented with in-hospital cardiac arrest (IHCA), and 25/87 presented with out-of-hospital cardiac arrest (OHCA). Overall survival to decannulation and hospital discharge rates were 26.4% and 25.3%, respectively. Among survivors (n=22), 19 presented with IHCA (30.6%), whilst only 3 survivors presented with OHCA (12%). A total of 15/87 (17%) patients were alive at 6-month follow-up. All survivors had good neurological function assessed as Cerebral Performance Category 1 or 2. Multivariate logistic regression to predict survival to hospital discharge showed that IHCA was the only independent predictor (Odds Ratio 5.8, p =0.042), however, this positive association disappeared after adjusting for the first left ventricular ejection fraction after resuscitation. CONCLUSION: In this study, the use of ECPR for IHCA was associated with a higher survival to discharge compared to OHCA. This study demonstrated a comparable survival rate to other established centers, particularly for IHCA. Neurological outcomes were comparable in both IHCA and OHCA survivors. However, large multicenter studies are warranted for better under-standing and improving the outcomes.

Clinical pharmacists' interventions for preventing adverse events in critically ill neonates in Qatar: an economic impact analysis.

Objective: This study aimed to assess the overall economic impact of clinical pharmacist interventions in the neonatal ICU (NICU) in Qatar. Methods: A retrospective review of neonates' records was performed over a 3-month duration in the NICU of Qatar to determine the total economic benefit of clinical pharmacist interventions. The total benefit of interventions was calculated by considering the cost avoidance due to preventable adverse drug events (ADEs) and the cost savings associated with the revised resource use due to interventions. Sensitivity analyses were conducted to ensure the robustness and generalizability of the results. Results: A total of 513 interventions were analyzed, involving 150 neonates. Most of the drug-related problems were related to therapy dosing, followed by drug choice appropriateness, the addition of prophylactic treatment, and administration frequency. The overall annual benefit was estimated at QAR 4,178,352 (1,147,584), which consisted of cost avoidance of QAR 1,050,680 (USD 288,648) and an overall cost saving of QAR -6091 (USD -1673). Conclusions: While the clinical pharmacist interventions led to increased resource utilisation and associated costs, when considering the avoided costs of ADEs, the overall clinical pharmacist practices in the NICU setting were economically beneficial.

Beta-blocker therapy in heart failure with preserved ejection fraction (B-HFpEF): A systematic review and meta-analysis.

INTRODUCTION: While beta-blockers are considered the cornerstone of treatment for heart failure with reduced ejection fraction, the same may not apply to patients with heart failure with preserved ejection fraction (HFpEF). To date, the benefit of beta-blockers remains uncertain, and there is no current consensus on their effectiveness. This study sought to evaluate the efficacy of beta-blockers on mortality and rehospitalization among patients with HFpEF. METHODS: A systematic review and meta-analysis of randomized or observational cohort studies examined the efficacy of beta-blocker therapy in comparison with placebo, control, or standard medical care in patients with HFpEF, defined as left ventricular ejection fraction ≥50 %. The main endpoints were mortality (i.e., all-cause and cardiovascular), rehospitalization (i.e., all-cause and for heart failure) and a composite of the two. RESULTS: Out of the 13,189 records initially identified, 16 full-text records met the inclusion criteria and were analyzed recruiting a total of 27,188 patients. The mean age range was 62-84 years old, predominantly female, with HFpEF in which 63.4 % of patients received a beta-blocker and 36.6 % did not. The pooled analysis of included cohort studies, of variable follow-up durations, showed a significant reduction in all-cause mortality by 19 % (odds ratio (OR) 0.81; 95 % confidence interval (CI): 0.65-0.99, p = 0.044) whereas rehospitalization for heart failure (OR 1.13; 95 % CI: 0.91-1.41, p = 0.27) or its composite with all-cause mortality (OR 1.01; 95 % CI: 0.78-1.32, p = 0.92) were similar between the beta-blocker and control groups. CONCLUSION: This meta-analysis showed that beta-blocker therapy has the potential to reduce all-cause mortality in patients with HFpEF based on observational studies. Nevertheless, it did not affect rehospitalization for heart failure or its composite with all-cause mortality. Large scale randomized trials are needed to clarify this uncertainty.

Percutaneous Mitral Valve Repair for Secondary Mitral Regurgitation: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to investigate whether percutaneous mitral valve repair (PMVr) using MitraClip was more effective than surgery or medical therapy for long-term morbidity and mortality. We searched MEDLINE, EMBASE, and CENTRAL (Cochrane Library) databases to identify relevant studies that recruited adult patients with functional or secondary mitral valve regurgitation who underwent PMVr with MitraClip implantation using appropriate search terms and Boolean operators. The odds ratios (ORs) were pooled using the random-effects model. A total of 14 studies recruiting 2,593 patients were included. Within 12 months of follow-up, patients who underwent PMVr did not maintain mitral valve regurgitation grade 2+ (OR 0.22, 95% confidence interval [CI] 0.12 to 0.41, p <0.0001, I2 = 0.0%, p = 0.52) or symptom-free heart failure (OR 0.47, 95% CI 0.29 to 0.77, p = 0.0028, I2 = 0.0%, p = 0.66) compared with their surgical counterparts. Patients were more likely to be rehospitalized for heart failure (OR 2.79, 95% CI 1.54 to 5.05, p = 0.0007, I2 = 0.0%, p = 0.51). However, there was no difference between the groups in terms of all-cause or cardiovascular mortality. Whereas, in comparison with medical therapy, PMVr significantly reduced all-cause mortality at 12 and ≥24 months of follow-up (OR 0.41, 95% CI 0.24, 0.69, p = 0.0009, I2 = 32%, p = 0.23 and OR 0.55, 95% CI 0.40, 0.75, p = 0.0002, I2 = 0.0%, p = 0.45, respectively). In conclusion, there was no difference in all-cause death at 12 or 24 months of follow-up between PMVr and the surgical approach, but the durability of valvular repair was inferior with PMVr. In comparison with medical therapy, there was a significant reduction in mortality with PMVr.

Spontaneous coronary artery dissection: an overview.

The prevalence of spontaneous coronary artery dissection (SCAD) has increased over the last decades in young adults presenting with acute coronary syndrome. Although the diagnostic tools, including intracoronary imaging, have permitted a more accurate diagnosis of SCAD, the prognosis and overall outcomes remain dismal. Furthermore, the disproportionate sex distribution affecting more women and the underdiagnosis in many parts of the world render this pathology a persistent clinical challenge, particularly since the management remains largely supportive with a limited and controversial role for percutaneous or surgical interventions. The purpose of this review is to summarize the available literature on SCAD and to provide insights into the gaps in knowledge and areas requiring further investigation.

Revisiting Beta-Blocker Therapy in Heart Failure with Preserved Ejection Fraction.

Heart failure with preserved ejection fraction (HFpEF) is a heterogenous disorder and tends to be predominant in elderly, female, and obese patients. HFpEF has been classified using various cut-offs of left ventricular ejection fraction in the published studies with a current cut-off of ≥50%. The evidence of beta-blocker therapy in HFpEF patients showed conflicting findings with variably reported efficacy. This review aims to examine the published studies on the use of beta blockers for the treatment of patients with HFpEF.

Percutaneous Mitral-Valve Intervention for Secondary Mitral Regurgitation: Data From Real-Life.

Many questions were raised due to the divergent results between cardiovascular outcomes assessment of the MitraClip percutaneous therapy for heart failure patients with functional mitral regurgitation (COAPT) and multicenter study of percutaneous mitral valve Repair MitraClip device in patients with severe secondary mitral regurgitation (MITRA-FR) trials on the use of percutaneous mitral valve repair for secondary mitral regurgitation. This paper examined pooled patients' characteristics and outcomes from real-life experience compared with those in the 2 landmark trials. A comprehensive search identified eligible studies published in 2020 and 2021. Mean difference and odds ratio (OR) were used to compare continuous and categorical data. Thirty-three studies included more than 9200 patients. Patients in landmark trials were younger than in real-life, less likely to present with severe heart failure symptoms ([COAPT: OR 0.25; 95% CI: 0.21, 0.31]; [MITRA-FR: OR 0.32; 95% CI: 0.23, 0.45]) or severe mitral regurgitation grade (COAPT only: OR 0.57; 95% CI: 0.45, 0.71) with larger left ventricular end diastolic volume. Procedure success (OR 1.94; 95% CI: 1.10, 3.40) was more frequent with lower all-cause mortality (OR 0.73; 95% CI: 0.54, 0.99) in COAPT. Real-life patients experienced more favorable procedural and clinical outcomes compared with MITRA-FR patients. Real-life data on percutaneous mitral valve repair in secondary mitral regurgitation showed important variations in patient selection and procedural outcomes. Rates of death and heart failure hospitalization in observational studies were lower than MITRA-FR but higher than COAPT trial.

Implications of the medication regimen complexity index score on hospital readmissions in elderly patients with heart failure: a retrospective cohort study.

BACKGROUND: The likelihood of elderly patients with heart failure (HF) being readmitted to the hospital is higher if they have a higher medication regimen complexity index (MRCI) compared to those with a lower MRCI. The objective of this study was to investigate whether there is a correlation between the MRCI score and the frequency of hospital readmissions (30-day, 90-day, and 1-year) among elderly patients with HF. METHODS: In this single-center retrospective cohort study, MRCI scores were calculated using a well-established tool. Patients were categorized into high (≥ 15) or low (< 15) MRCI score groups. The primary outcome examined the association between MRCI scores and 30-day hospital readmission rates. Secondary outcomes included the relationships between MRCI scores and 90-day readmission, one-year readmission, and mortality rates. Multivariate logistic regression was employed to assess the 30- and 90-day readmission rates, while Kaplan-Meier analysis was utilized to plot mortality. RESULTS: A total of 150 patients were included. The mean MRCI score for all patients was 33.43. 90% of patients had a high score. There was no link between a high MCRI score and a high 30-day readmission rate (OR 1.02; 95% CI 0.99-1.05; p < 0.13). A high MCRI score was associated with an initial significant increase in the 90-day readmission rate (odd ratio, 1.03; 95% CI, 1.00-1.07; p < 0.022), but not after adjusting for independent factors (odd ratio, 0.99; 95% CI, 0.95-1.03; p < 0.487). There was no significant difference between high and low MRCI scores in their one-year readmission rate. CONCLUSION: The study's results indicate that there is no correlation between a higher MRCI score and the rates of hospital readmission or mortality among elderly patients with HF. Therefore, it can be concluded that the medication regimen complexity index does not appear to be a significant predictor of hospital readmission or mortality in this population.

Artificial intelligence in sickle disease.

Artificial intelligence (AI) is rapidly becoming an established arm in medical sciences and clinical practice in numerous medical fields. Its implications have been rising and are being widely used in research, diagnostics, and treatment options for many pathologies, including sickle cell disease (SCD). AI has started new ways to improve risk stratification and diagnosing SCD complications early, allowing rapid intervention and reallocation of resources to high-risk patients. We reviewed the literature for established and new AI applications that may enhance management of SCD through advancements in diagnosing SCD and its complications, risk stratification, and the effect of AI in establishing an individualized approach in managing SCD patients in the future. Aim: to review the benefits and drawbacks of resources utilizing AI in clinical practice for improving the management for SCD cases.

A practical guide to managing cardiopulmonary toxicities of tyrosine kinase inhibitors in chronic myeloid leukemia.

Tyrosine kinase inhibitors (TKIs) have revolutionized the treatment of chronic myeloid leukemia (CML) but their use was associated with a range of serious cardiopulmonary toxicities including vascular adverse events, QT prolongation, heart failure, pleural effusion, and pulmonary arterial hypertension. Dedicated clinical management guidelines for TKI-induced toxicities are not available. This review aims to discuss TKI-associated cardiopulmonary toxicities and proposes a practical guide for their management.

Impact of Clinical Pharmacist Interventions on Economic Outcomes in a Cardiology Setting in Qatar.

We sought to investigate the economic impact of preventing adverse events in a cardiology setting in Qatar as an effect of the clinical pharmacist as an intervention. This is a retrospective study of interventions by clinical pharmacists within an adult cardiology setting in a public healthcare setting (i.e Hamad Medical Corporation). The study included interventions that took place in March 2018, July 15, 2018 to August 15, 2018, and January 2019. The economic impact was measured via calculating the total benefit, defined as the sum of the cost savings and the cost avoidance. Sensitivity analyses were adopted to confirm the robustness of the results. The pharmacist intervened in 262 patients, resulting in 845 interventions, with appropriate therapy (58.6%) and dosing/administration (30.2%) being the most frequent categories of reported interventions. Cost savings and cost avoidance resulted in QAR-11,536 (USD-3169) and QAR1,607,484 (USD 441,616), respectively, yielding a total benefit of QAR1,595,948 (USD 438,447) per 3 months and QAR6,383,792 (USD 1,753,789) per a year.

Transcatheter Mitral Valve Repair in Acute and Critical Cardiac Conditions.

Acute mitral valve regurgitation (MR) is an emergency condition that requires an early diagnosis of the etiology and rapid management. Surgical intervention is the first-line treatment for acute severe MR. However, many patients are denied surgical intervention due to the acute risk of surgery. Transcatheter mitral valve repair (TMVr) is a less invasive technique and becoming a potential alternative to surgery in inoperable patients but is underrepresented in the literature. This review aims to discuss the published data on the use of TMVr in unstable MR patients presenting with acute or critical cardiac conditions.

Applications of Machine Learning in Chronic Myeloid Leukemia.

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm characterized by dysregulated growth and the proliferation of myeloid cells in the bone marrow caused by the BCR-ABL1 fusion gene. Clinically, CML demonstrates an increased production of mature and maturing granulocytes, mainly neutrophils. When a patient is suspected to have CML, peripheral blood smears and bone marrow biopsies may be manually examined by a hematologist. However, confirmatory testing for the BCR-ABL1 gene is still needed to confirm the diagnosis. Despite tyrosine kinase inhibitors (TKIs) being the mainstay of treatment for patients with CML, different agents should be used in different patients given their stage of disease and comorbidities. Moreover, some patients do not respond well to certain agents and some need more aggressive courses of therapy. Given the innovations and development that machine learning (ML) and artificial intelligence (AI) have undergone over the years, multiple models and algorithms have been put forward to help in the assessment and treatment of CML. In this review, we summarize the recent studies utilizing ML algorithms in patients with CML. The search was conducted on the PubMed/Medline and Embase databases and yielded 66 full-text articles and abstracts, out of which 11 studies were included after screening against the inclusion criteria. The studies included show potential for the clinical implementation of ML models in the diagnosis, risk assessment, and treatment processes of patients with CML.

Optimum heparin dose in off-pump coronary artery bypass grafting: A systematic review and meta-analysis.

INTRODUCTION: Off-pump coronary artery bypass grafting (OPCABG) was introduced many years ago aiming to reduce the known complications of conventional on-pump coronary surgeries. Heparin is required during the procedures, but the available protocols have diverse dosage regimens. The primary objective of this systematic review is to examine the effect of different heparin doses on the outcomes of OPCABG. EVIDENCE ACQUISITION: MEDLINE and EMBASE were searched. Four reviewers identified eligible clinical trials. Two reviewers extracted data and independently assessed the risk of bias using Cochrane tool. The primary outcome was the activated clotting time (ACT) at three minutes. The secondary outcomes were proportion of patients requiring blood products and the length of hospital stay. An aggregate data approach was used. EVIDENCE SYNTHESIS: Three single-center randomized studies recruiting 256 patients were included. The studies compared low-dose (1.5-2 mg/kg) and high-dose (3 mg/kg) heparin boluses. The overall mean difference for ACT after three minutes between low- and high-dose heparin is - 126.16 (95% CI: - 142.19, - 110.14). The proportion of patients requiring blood products after surgery [odd ratio 1.27 (95% CI: 0.69, 2.32)] or the overall length of stay [mean difference -0.15 (95% CI: -0.84, 0.53)] did not differ between the heparin doses. CONCLUSIONS: In OPCABG, high-dose compared with low-dose heparin did not affect the utilization of more blood products or increased the overall length of stay. Unsurprisingly, ACT values were higher in the high-dose heparin group. Larger and adequately powered randomized clinical trials are indicated to resolve the uncertainty.

Effectiveness of a structured pharmacist-delivered intervention for patients post-acute coronary syndromes on all-cause hospitalizations and cardiac-related hospital readmissions: a prospective quasi-experimental study.

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity in Qatar and globally. AIM: The primary objective of the study was to evaluate the effectiveness of a structured clinical pharmacist-delivered intervention on all-cause hospitalizations and cardiac-related readmissions in patients with ACS. METHOD: A prospective quasi-experimental study was conducted at Heart Hospital in Qatar. Discharged ACS patients were allocated to one of three study arms: (1) an intervention group (received a structured clinical pharmacist-delivered medication reconciliation and counselling at discharge, and two follow-up sessions at 4 weeks and 8 weeks post-discharge), (2) a usual care group (received the general usual care at discharge by clinical pharmacists) or, (3) a control group (discharged during weekends or after clinical pharmacists' working hours). Follow-up sessions for the intervention group were designed to re-educate and counsel patients about their medications, remind them about the importance of medication adherence, and answer any questions they may have. At the hospital, patients were allocated into one of the three groups based on intrinsic and natural allocation procedures. Recruitment of patients took place between March 2016 and December 2017. Data were analyzed based on intention-to-treat principles. RESULTS: Three hundred seventy-three patients were enrolled in the study (intervention = 111, usual care = 120, control = 142). Unadjusted results showed that the odds of 6-month all-cause hospitalizations were significantly higher among the usual care (OR 2.034; 95% CI: 1.103-3.748, p = 0.023) and the control arms (OR 2.704; 95% CI: 1.456-5.022, p = 0.002) when compared to the intervention arm. Similarly, patients in the usual care arm (OR 2.304; 95% CI: 1.122-4.730, p = 0.023) and the control arm (OR 3.678; 95% CI: 1.802-7.506, p ≤ 0.001) had greater likelihood of cardiac-related readmissions at 6 months. After adjustment, these reductions were only significant for cardiac-related readmissions between control and intervention groups (OR 2.428; 95% CI: 1.116-5.282, p = 0.025). CONCLUSION: This study demonstrated the impact of a structured intervention by clinical pharmacists on cardiac-related readmissions at 6 months post-discharge in patients post-ACS. The impact of the intervention on all-cause hospitalization was not significant after adjustment for potential confounders. Large cost-effective studies are required to determine the sustained impact of structured clinical pharmacist-provided interventions in ACS setting. TRIAL REGISTRATION: Clinical Trials: NCT02648243 Registration date: January 7, 2016.