N-Terminal Pro B-Type Natriuretic Peptide as a Screening Tool for Inpatient Echocardiogram Requirement Among Patients With Suspected Heart Failure: Using NT-proBNP to Reduce Hospital Length of Stay.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a cardiac biomarker with diagnostic and prognostic utility in patients with heart failure (HF). Whether NT-proBNP can be used to triage inpatient transthoracic echocardiogram (TTE) requirements, and whether this impacts hospital length of stay (LOS), is not clear. METHODS: Clinical and biochemical data were prospectively recorded on all inpatients at Wollongong Hospital, NSW, Australia, who had a TTE ordered for suspected HF over a 6-month period. NT-proBNP was used to triage TTE priority, where high-priority inpatient TTE, lower-priority inpatient TTE and outpatient (OP) TTE were performed for serum NT-proBNPs of ≥900, 300-899 and <300, respectively. Outcomes were compared with a baseline cohort of HF inpatients in whom TTE requirement was not guided by NT-proBNP. RESULTS: A total of 236 patients were evaluated-31, 31, and 174 in the low, intermediate and high NT-proBNP cohorts, respectively, and 199 patients were in the baseline cohort. Average hospital LOS was significantly reduced in the study cohort compared to baseline (9.97 vs 13.87 days, p<0.001). Of the 31 patients with a very low NT-proBNP who were discharged for OP TTE, seven were readmitted within 30 days, though none were HF-related. There were no deaths at 30 days in the low or intermediate NT-proBNP groups. CONCLUSIONS: Using NT-proBNP to triage requirements for inpatient TTE reduces hospital LOS. A very low NT-proBNP may help identify which patients with suspected HF can be safely discharged for OP TTE.

Clinical predictors and management for radial artery spasm: an Australian cross-sectional study.

INTRODUCTION: The transradial approach for coronary artery catheterisation has increased in popularity compared to the transfemoral approach for patients undergoing percutaneous coronary interventions. However, radial artery spasm continues to be a major complication of the procedure. Current management strategies vary concerning radial artery spasm and there is limited evidence of practice in the Australian context. AIM: To identify the predictors of radial artery spasm and the medications used for its prevention and management. METHODS: A descriptive cross-sectional study was carried out over a three-month period in two tertiary hospitals in NSW, Australia. A self-administered pre-procedural survey was completed by patients undergoing coronary artery catheterisation. This survey collected socio-demographic data and assessed anxiety using the Spielberger State-Trait Anxiety Inventory. Procedural data, including length of procedure, equipment used, occurrence of radial artery spasm, and medications given, were collected post-procedure by the interventionalist. RESULTS: Of the 169 participants, over half were male (59.8%) and aged 66 years or older (56.8%). Radial artery spasm was reported in 24 (14.2%) participants. Rates of spasm were significantly higher among females (66.6%, p = 0.004), those aged under 65 years (62.5%, p = 0.001) and those who reported a medical history of anxiety (33.3%, p = 0.0004). There were no significant differences in State and Trait anxiety scores among those who had RAS and those who did not. Logistic regression identified younger age as the only statistically significant predictor of RAS (OR 0.536; 95% CI 0.171-1.684; p = 0.005). To prevent radial artery spasm most patients received midazolam (n = 158; 93.5%), nitrates (n = 133; 78.7%) and/or fentanyl (n = 124; 73.4%) prophylactically. Nitrates were the most frequently administered medication to treat radial artery spasm (78.7%). CONCLUSION: This study highlights that there is a need to develop a clearer understanding of the predictors of RAS, as identifying patients at risk can ensure prophylactic measures are implemented. This study identified nitrates as the preferred vasodilator as a preventative measure along with the use of sedation.

Impact of Medication Nonadherence in a Clinical Trial of Dual Antiplatelet Therapy.

BACKGROUND: Nonadherence to antiplatelet therapy after percutaneous coronary intervention (PCI) is common, even in clinical trials. OBJECTIVES: The purpose of this study was to investigate the impact of nonadherence to study protocol regimens in the MASTER DAPT (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Prolonged DAPT Regimen) trial. METHODS: At 1-month after PCI, 4,579 high bleeding risk patients were randomized to single antiplatelet therapy (SAPT) for 11 months (or 5 months in patients on oral anticoagulation [OAC]) or dual antiplatelet therapy (DAPT) for ≥2 months followed by SAPT. Coprimary outcomes included net adverse clinical events (NACE), major adverse cardiac and cerebral events (MACE), and major or clinically relevant nonmajor bleeding (MCB) at 335 days. Inverse probability-of-censoring weights were used to correct for nonadherence Academic Research Consortium type 2 or 3. RESULTS: In total, 464 (20.2%) patients in the abbreviated-treatment and 214 (9.4%) in the standard-treatment groups incurred nonadherence Academic Research Consortium type 2 or 3. At inverse probability-of-censoring weights analyses, NACE (HR: 1.01; 95% CI: 0.88-1.27) or MACE (HR: 1.07; 95% CI: 0.83-1.40) did not differ, and MCB was lower with abbreviated compared with standard treatment (HR: 0.51; 95% CI: 0.60-0.73) consistently across OAC subgroups; among OAC patients, SAPT discontinuation 6 months after PCI was associated with similar MACE and lower MCB (HR: 0.47; 95% CI: 0.22-0.99) compared with SAPT continuation. CONCLUSIONS: In the MASTER DAPT adherent population, 1-month compared with ≥3-month DAPT was associated with similar NACE or MACE and lower MCB. Among OAC patients, SAPT discontinuation after 6 months was associated with similar MACE and lower MCB than SAPT continuation (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Prolonged DAPT Regimen [MASTER DAPT]; NCT03023020).

Association of hypertension with mortality in patients hospitalised with COVID-19.

OBJECTIVE: To assess whether hypertension is an independent risk factor for mortality among patients hospitalised with COVID-19, and to evaluate the impact of ACE inhibitor and angiotensin receptor blocker (ARB) use on mortality in patients with a background of hypertension. METHOD: This observational cohort study included all index hospitalisations with laboratory-proven COVID-19 aged ≥18 years across 21 Australian hospitals. Patients with suspected, but not laboratory-proven COVID-19, were excluded. Registry data were analysed for in-hospital mortality in patients with comorbidities including hypertension, and baseline treatment with ACE inhibitors or ARBs. RESULTS: 546 consecutive patients (62.9±19.8 years old, 51.8% male) hospitalised with COVID-19 were enrolled. In the multivariable model, significant predictors of mortality were age (adjusted OR (aOR) 1.09, 95% CI 1.07 to 1.12, p<0.001), heart failure or cardiomyopathy (aOR 2.71, 95% CI 1.13 to 6.53, p=0.026), chronic kidney disease (aOR 2.33, 95% CI 1.02 to 5.32, p=0.044) and chronic obstructive pulmonary disease (aOR 2.27, 95% CI 1.06 to 4.85, p=0.035). Hypertension was the most prevalent comorbidity (49.5%) but was not independently associated with increased mortality (aOR 0.92, 95% CI 0.48 to 1.77, p=0.81). Among patients with hypertension, ACE inhibitor (aOR 1.37, 95% CI 0.61 to 3.08, p=0.61) and ARB (aOR 0.64, 95% CI 0.27 to 1.49, p=0.30) use was not associated with mortality. CONCLUSIONS: In patients hospitalised with COVID-19, pre-existing hypertension was the most prevalent comorbidity but was not independently associated with mortality. Similarly, the baseline use of ACE inhibitors or ARBs had no independent association with in-hospital mortality.

Cardiac Complications in Patients Hospitalised With COVID-19 in Australia.

OBJECTIVES: Describe the incidence of cardiac complications in patients admitted to hospital with COVID-19 in Australia. DESIGN: Observational cohort study. SETTING: Twenty-one (21) Australian hospitals. PARTICIPANTS: Consecutive patients aged ≥18 years admitted to hospital with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. MAIN OUTCOME MEASURES: Incidence of cardiac complications. RESULTS: Six-hundred-and-forty-four (644) hospitalised patients (62.5±20.1 yo, 51.1% male) with COVID-19 were enrolled in the study. Overall in-hospital mortality was 14.3%. Twenty (20) (3.6%) patients developed new atrial fibrillation or flutter during admission and 9 (1.6%) patients were diagnosed with new heart failure or cardiomyopathy. Three (3) (0.5%) patients developed high grade atrioventricular (AV) block. Two (2) (0.3%) patients were clinically diagnosed with pericarditis or myopericarditis. Among the 295 (45.8%) patients with at least one troponin measurement, 99 (33.6%) had a peak troponin above the upper limit of normal (ULN). In-hospital mortality was higher in patients with raised troponin (32.3% vs 6.1%, p<0.001). New onset atrial fibrillation or flutter (6.4% vs 1.0%, p=0.001) and troponin elevation above the ULN (50.3% vs 16.4%, p<0.001) were more common in patients 65 years and older. There was no significant difference in the rate of cardiac complications between males and females. CONCLUSIONS: Among patients with COVID-19 requiring hospitalisation in Australia, troponin elevation was common but clinical cardiac sequelae were uncommon. The incidence of atrial arrhythmias and troponin elevation was greatest in patients 65 years and older.

Preprocedural Anxiety in the Transradial Cardiac Catheterization Era.

BACKGROUND: Transradial cardiac catheterization is increasingly being used for the management of coronary artery disease given the low risk of procedural discomfort and complications with this approach. However, the evidence relating to preprocedural anxiety levels in these patients is scarce. OBJECTIVE: The aim of this study was to evaluate the anxiety levels and the predictors of anxiety in patients undergoing transradial cardiac catheterization procedures. METHODS: Data were collected using a self-administered survey. Anxiety was measured using the Spielberg's State-Trait Anxiety Inventory questionnaire. Multiple regression analysis was used to identify whether gender, age, family history of heart disease, smoking status, history of depression, and trait anxiety scores were predictors of preprocedural anxiety. RESULTS: A total of 198 patients participated in this study. More than half of the patients (53.5%) were classified as having a high state anxiety level. The mean (SD) preprocedural trait and state anxiety scores were 35.34 (9.8) and 36.43 (11.4), respectively. Female patients, those younger than 65 years, current smokers, and those with a family history of heart disease, a history of depression, and a history of anxiety had significantly higher anxiety scores. Having high trait anxiety scores was the only predictor of preprocedural anxiety. CONCLUSION: Although the transradial approach has a low procedural risk and causes less discomfort to the patient, anxiety persists in more than 50% of patients, with trait anxiety being the best predictor. Nurses should therefore try to decrease anxiety levels in the preprocedural phase to minimize postprocedural adverse outcomes in this group of patients.

Colchicine in Patients With Acute Coronary Syndrome: The Australian COPS Randomized Clinical Trial.

BACKGROUND: Inflammation plays a crucial role in clinical manifestations and complications of acute coronary syndromes (ACS). Colchicine, a commonly used treatment for gout, has recently emerged as a novel therapeutic option in cardiovascular medicine owing to its anti-inflammatory properties. We sought to determine the potential usefulness of colchicine treatment in patients with ACS. METHODS: This was a multicenter, randomized, double-blind, placebo-controlled trial involving 17 hospitals in Australia that provide acute cardiac care service. Eligible participants were adults (18-85 years) who presented with ACS and had evidence of coronary artery disease on coronary angiography managed with either percutaneous coronary intervention or medical therapy. Patients were assigned to receive either colchicine (0.5 mg twice daily for the first month, then 0.5 mg daily for 11 months) or placebo, in addition to standard secondary prevention pharmacotherapy, and were followed up for a minimum of 12 months. The primary outcome was a composite of all-cause mortality, ACS, ischemia-driven (unplanned) urgent revascularization, and noncardioembolic ischemic stroke in a time to event analysis. RESULTS: A total of 795 patients were recruited between December 2015 and September 2018 (mean age, 59.8±10.3 years; 21% female), with 396 assigned to the colchicine group and 399 to the placebo group. Over the 12-month follow-up, there were 24 events in the colchicine group compared with 38 events in the placebo group (P=0.09, log-rank). There was a higher rate of total death (8 versus 1; P=0.017, log-rank) and, in particular, noncardiovascular death in the colchicine group (5 versus 0; P=0.024, log-rank). The rates of reported adverse effects were not different (colchicine 23.0% versus placebo 24.3%), and they were predominantly gastrointestinal symptoms (colchicine, 23.0% versus placebo, 20.8%). CONCLUSIONS: The addition of colchicine to standard medical therapy did not significantly affect cardiovascular outcomes at 12 months in patients with ACS and was associated with a higher rate of mortality. Registration: URL: https://www.anzctr.org.au; Unique identifier: ACTRN12615000861550.

The effect of topical medications on radial artery spasm in patients undergoing transradial coronary procedures: a systematic review.

OBJECTIVE: The objective of this review was to identify the effectiveness of topical medications on radial artery spasm (RAS) in patients undergoing transradial percutaneous coronary procedures. INTRODUCTION: Percutaneous coronary procedures were traditionally carried out via the femoral artery; however, over the last 20 years there has been a global increase in the number of proceduralists carrying out percutaneous coronary procedures via the transradial approach. Radial artery spasm remains an issue for the transradial approach, potentially leading to procedural failure. Topical medications have been suggested to reduce the occurrence of RAS during transradial percutaneous coronary procedures. INCLUSION CRITERIA: This review considered papers that included participants aged 18 years and over undergoing non-emergency transradial percutaneous coronary procedures. This review considered papers on the utilization of topical medications prior to commencing the transradial approach for percutaneous coronary procedures to reduce RAS. Topical medications were compared to other medications. The primary outcome was the incidence of RAS as assessed by angiography or ultrasound or resistance felt by the operator while manipulating the catheter. Other outcomes of interest included change in radial artery diameter, measured by angiography or ultrasound, change in radial artery patency and side effects of medications administered. Randomized and quasi-randomized controlled trials were considered. METHODS: A three-step search strategy was utilized in this review. A search of various databases was carried out followed by a search for unpublished literature between 1989 to January 2017. Only papers published in English were included in the review. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instrument from the Joanna Briggs Institute (JBI). There was no need for a third reviewer. Quantitative data was extracted from papers included in the review using the JBI data extraction instrument and entered in to RevMan5 (Copenhagen: The Nordic Cochrane Centre, Cochrane). All results were subject to double data entry. Effect sizes were expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis. RESULTS: Only three studies involving 697 participants met the inclusion criteria. There was a statistically significant reduction in the incidence of RAS in patients treated with a eutectic mixture of local anesthetics compared to subcutaneous lidocaine (OR 0.26; 95%CI 0.07,0.96). However there were no significant differences in RAS in studies that compared eutectic mixture of local anesthetics and placebo or a combinations of lidocaine with nitroglycerine compared to placebo. CONCLUSIONS: It is difficult to draw a valid conclusion, given the low number of studies, small sample sizes and heterogeneity between the studies.

Safety and efficacy of ulnar artery approach for percutaneous cardiac catheterization: Systematic review and meta-analysis.

BACKGROUND: Trans-radial access has rapidly become the standard for percutaneous coronary procedures in the last decade. As proceduralists overcome the learning curve and become more competent in trans-radial access, alternative safe access sites such as the ulnar artery have been increasingly used for emergent and elective procedures. The aim of this study was to synthesize the best available evidence of the impact on major adverse cardiac events (MACE) of ulnar artery compared to radial artery cardiac catheterization. METHODS: This review considered randomized controlled trials that included adult patients who had a percutaneous coronary procedure via the radial or ulnar artery. The intervention of interest was the use of ulnar compared to radial artery for cardiac catheterization. An extensive search was undertaken for published and unpublished trials up to May 2017. Methodological quality was assessed independently by two reviewers using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) checklist. Data were analyzed using Review Manager. RESULTS: A total of six trials were included in the review. There was no statistically significant difference in the incidence of MACE between patients who underwent trans-ulnar or trans-radial artery catheterization (OR 0.90; 95% CI 0.65-1.25). Complications associated with access including hematoma formation, (n = 6 trials) pseudo-aneurysm, and arterio-venous fistulae formation (n = 5 trials), were investigated in a total of 5,276 patients, with no difference in these complications noted between the two groups. There were no differences in arterial access time, fluoroscopy time, and contrast load between the two groups. CONCLUSIONS: There is evidence to support safe use of the ulnar artery as an alternative to the radial artery for access for cardiac catheterization.

Novel ECG changes in acute coronary syndromes. Would improvement in the recognition of 'STEMI-equivalents' affect time until reperfusion?

Current guidelines recommend that patients with non-ST elevation myocardial infarction (NSTEMI) are treated with medical management alone, or in combination with coronary angiography within 24 h. Recent research suggests that NSTEMIs show angiographic evidence of complete occlusion at rates comparable to STEMIs, suggesting a subgroup of NSTEMI patients who require urgent angiography. Novel ECG changes, termed 'STEMI-equivalents', have been described as a way of identifying this subgroup. The aim of this study was to determine whether patients with STEMI-equivalent ECG changes experience similar degrees of myocardial damage, and would thus benefit from urgent PCI. Cardiac catheterisation databases at The Wollongong Hospital were searched for STEMI, and NSTEMI patients with complete occlusion of the culprit vessel, between January 2011 and December 2013. A total of 1429 patients underwent angiography during this time period. Of these, 220 were eligible for ECG analysis. We found 10-25% of NSTEMIs with 'STEMI equivalent' ECG changes correlated with complete vessel occlusion on angiography. These patients demonstrated equivalent initial troponin readings. Recognition of STEMI-equivalents represent a chance for earlier intervention with prompt coronary angiography, as these findings are often associated with complete occlusion of the culprit vessel. These findings provide further evidence supporting the potential inclusion of STEMI-equivalents in future ACS guidelines.

Novel Oral Anticoagulants in Direct Current Cardioversion for Atrial Fibrillation.

BACKGROUND: For some patients with atrial fibrillation, direct current cardioversion (DCCV) is one strategy that can be used to establish sinus rhythm but appropriate anticoagulation is mandatory to prevent thromboembolic events. Historically, patients were anticoagulated with warfarin with bridging with unfractionated or low molecular weight heparin, however, recently novel oral anticoagulants (NOACs), apixaban, dabigatran and rivaroxaban have become more popular. Despite the increase in use, real world data on safety and efficacy is limited. METHODS: We retrospectively analysed patients that underwent DCCV at Wollongong Hospital from 1 January 2014 to 30 June 2016 and compared peri-procedural anticoagulation with warfarin and the three NOACs. Patients were treated with at least 24hours of anticoagulation before and at least four weeks after the procedure unless contraindication developed. All patients underwent transoesophageal echocardiography prior to cardioversion regardless of anticoagulation type or duration. Patients with left atrial or left atrial appendage thrombus did not undergo cardioversion. We analysed the utilisation rates of NOACs and compared the incidence of post procedural ischaemic strokes and major bleeding events at eight weeks follow-up. RESULTS: Over the study period, 284 patients underwent DCCV; 109 (38.4%) patients were anticoagulated with warfarin and 175 (61.6%) with one of the three NOACs; 77 (27.1%) with apixaban, 60 (21.1%) with rivaroxaban and 38 (13.4%) with dabigatran. Patients treated with warfarin were on average older (71.3±9.7 vs. 65.2±12.9; p value, 0.0005) with more cardiac risk factors including documented heart failure with reduced ejection fraction (39.4% vs. 22.9%; p value, 0.0032), medically treated hypertension (76.1% vs. 48.6%; p value, 0.0001) and peripheral vascular disease (31.2% vs. 12.1%; p value, 0.0004). The NOACs were more frequently used in patients with lower CHA2DS2-VASc scores; 179 patients had a score≤3 with 52 (29.1%) patients treated with warfarin and 127 (70.9%) treated with a NOAC (p value, 0.0001). In our cohort, the use of NOACs increased over the study period from 45.6% in 2014 to 82.8% in 2016. There was a low incidence of ischaemic stroke and bleeding events in both groups, 1.8% versus 0.6% (p value, 0.5607) and 3.6% versus 1.7% (p value, 0.4343) respectively. In the NOAC group, 95 of the 174 patients were anticoagulation-naïve and anticoagulated for less than five days; in comparison to longer duration therapy there was no difference in ischaemic stroke and bleeding events. CONCLUSION: In our institution, the use of NOACs in electrical cardioversion increased significantly over the study period and in our experience, they appear to be as safe as warfarin with low rates of ischaemic stroke and major bleeding. In addition, a short duration NOAC strategy was comparable to longer duration therapy.

The effect of vasodilatory medications on radial artery spasm in patients undergoing transradial coronary artery procedures: a systematic review.

BACKGROUND: The uptake of percutaneous coronary procedures via the radial artery has increased internationally due to the decreased risk of complications and increased patient satisfaction. The increased susceptibility of the radial artery to spasm however presents a potential risk for procedural failure. Although most experts agree on the need for prophylactic medications to reduce radial artery spasm, currently there is inconsistency in literature regarding the most effective vasodilatory medication or combination of medications. REVIEW OBJECTIVE: The objective of this study is to identify the effectiveness of vasodilatory medications on radial artery spasm in patients undergoing transradial coronary artery procedures. INCLUSION CRITERIA TYPES OF PARTICIPANTS: This review considered studies that included participants aged 18 years and over undergoing non-emergent transradial percutaneous coronary artery procedures. TYPES OF INTERVENTION(S): This review considered studies that used vasodilating intravenous and intra-arterial medications or combinations of medications prior to commencing and during transradial coronary approaches to reduce radial artery spasm. OUTCOMES: The outcomes of interest were the incidence of radial artery spasm during percutaneous coronary procedure using objective and/or subjective measures and its effect on the successful completion of the procedure. TYPES OF STUDIES: Randomized controlled trials published in the English language between 1989 to date were considered for inclusion. SEARCH STRATEGY: The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. An initial search of MEDLINE, CINAHL and Scopus was undertaken, followed by a search for unpublished studies. ASSESSMENT OF METHODOLOGICAL QUALITY: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments. Any disagreements that arose between the reviewers were resolved through discussion. DATA EXTRACTION: Quantitative data was extracted from papers included in the review using the standardized data extraction tool from RevMan5 (Copenhagen: The Nordic Cochrane Centre, Cochrane). DATA SYNTHESIS: Quantitative data, where possible, was pooled in statistical meta-analysis using RevMan5. All results were subject to double data entry. Effect sizes expressed as risk ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis. RESULTS: Nine trials involving 3614 patients were included in the final review. Pooled data involving 992 patients on the effect of calcium channel blockers demonstrated a statistically significant reduction in the incidence of vasospasm in patients who received verapamil 5 mg compared to those who received a placebo (OR 0.33; 95%CI 0.19, 0.58). Similarly patients who received verapamil 2.5 mg or 1.25 mg had significantly fewer incidences of vasospasm when compared to those who received a placebo. Nitroglycerine 100mcg was demonstrated to be associated with a statistically significant reduction in the incidence of vasospasm. CONCLUSION: The evidence demonstrates a benefit in the use of vasodilatory medications for the reduction of vasospasm in patients having radial coronary procedures. Further large-scale multi-center trials are needed to determine the preferred medication.

Effects of methods used to achieve hemostasis on radial artery occlusion following percutaneous coronary procedures: a systematic review.

BACKGROUND: Transradial access to percutaneous coronary procedures is becoming the preferred access route, and it is being increasingly used for emergent and elective procedures. However, radial artery occlusion (RAO) continues to remain an adverse occurrence following sheath removal or in the first 24 hours following sheath removal due to the smaller diameter of the artery. OBJECTIVES: The overall objective of this study was to synthesize the best available research evidence related to the effects of methods used to achieve hemostasis on RAO rates after percutaneous coronary procedures. INCLUSION CRITERIA TYPES OF PARTICIPANTS: The current review considered trials that included adult patients (18 years and over) who have had a coronary angiography or coronary re-vascularization intervention via the radial artery. TYPES OF INTERVENTION(S): The interventions of interest were the use of various hemostatic methods compared to traditional interventions to prevent RAO. TYPES OF STUDIES: All randomized and quasi-randomized controlled trials evaluating the effect of various hemostatic methods on RAO rates after percutaneous coronary procedures were included in the review. OUTCOMES: The primary outcome of interest was the incidence of RAO at the time of discharge and persistent occlusion at the time of follow-up. SEARCH STRATEGY: The search aimed to find published and unpublished trials through electronic databases, reference lists and key reports. An extensive search was undertaken for the following databases - CINAHL, Embase, PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL). Databases were searched up to May 2016. The search for unpublished trials included Dissertation Abstracts International, World Cat, Clinicaltrials.gov, ProQuest Dissertation and Theses and MedNar. METHODOLOGICAL QUALITY: Methodological quality was assessed independently by two reviewers using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) checklist. Disagreements that arose between the reviewers were resolved through discussion. DATA EXTRACTION: Quantitative data were extracted from papers included in the review by one reviewer using the standardized data extraction tool from JBI-MAStARI. The data extracted were checked by a second reviewer. Disagreements that arose between the reviewers were resolved through discussion. All results were subject to double data entry in Review Manager. DATA SYNTHESIS: Statistical pooling of the data was not possible due to the heterogeneity of the trials; therefore, the findings are presented in narrative form. However, figures have been used to illustrate the results. RESULTS: A total of seven trials were included in the review. One trial demonstrated a significant reduction in RAO rates in patients who had a mean arterial pressure (MAP)-guided TR band to a standard TR band (odds ratio [OR] 0.08; 95% confidence interval [CI] 0.02, 0.37). A statistically significant reduction in the incidence of RAO was observed among patients who received a biopolymer dressing (Chitosen) compared to those who received the TR band (OR 2.20; 95% CI 1.20, 4.02). No statistically significant difference in the incidence of RAO was reported between those who received the TR band and those who received either the elastic bandage (P = 0.08) or T band (P = 0.76). Similarly, no statistically significant difference in rates of RAO among patients was reported among those who had pro-coagulant dressings compared to those who had short or long manual compression. One trial that compared the TR band to a MAP-guided TR band demonstrated no statistically significant difference in the time taken to obtain hemostasis between the two groups (P = 0.61). A statistically significant reduction in the time taken to obtain hemostasis was observed among patients who received the hemostatic biopolymer dressing compared to the TR band. No statistically significant difference in the incidence of hematoma was identified among patients who received pneumatic compression or traditional compression to achieve hemostasis. CONCLUSION: There is limited evidence to support the use of any single hemostatic method to prevent RAO rates after percutaneous coronary procedures. Although used extensively, there is evidence of no effect of the pneumatic compression method using the TR band on the incidence of RAO at discharge or follow-up, the time taken to obtain hemostasis and the incidence of hematoma. The MAP-guided compression method and the Biopolymer dressing (Chitosen) were superior to the TR band compression method, and patent hemostasis was superior to hemoband in the prevention of RAO. However, these results are based on single trials and should be interpreted with caution. The evidence obtained from the review does not provide a concrete base for the development of practice guidelines. Until more robust evidence is available, practices will continue to be dictated by local preferences and available resources.

Effects of topical medications on radial artery spasm in patients undergoing transradial coronary procedures: a systematic review protocol.

REVIEW OBJECTIVE: The objective is to identify the effectiveness of topical medications in reducing radial artery spasm in patients undergoing transradial coronary procedures.

Effects of methods used to achieve hemostasis on radial artery occlusion following percutaneous coronary procedures: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this systematic review is to synthesize the best available research evidence related to the effects of methods used to achieve hemostasis on radial artery occlusion (RAO) rates, following the radial artery approach for percutaneous coronary procedures.The specific review question is as follows: What is the effect of methods used to achieve hemostasis post sheath removal on RAO rates in adult patients, following the radial artery approach for percutaneous coronary procedures?

Effectiveness of vasodilatory medications on radial artery spasm in patients undergoing transradial coronary artery procedures: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The quantitative objective is to identify the effectiveness of vasodilatory medications on radial artery spasm in patients undergoing transradial coronary artery procedures.

Return to full normal activities including work at two weeks after acute myocardial infarction.

Patients are generally advised to return to full normal activities, including work, 6 to 8 weeks after acute myocardial infarction (AMI). We assessed the outcomes of early return to normal activities, including work at 2 weeks, after AMI in patients who were stratified to be at a low risk for future cardiac events. Patients were considered for randomization before discharge if they had no angina, had left ventricular ejection fraction >40%, a negative result from a symptom-limited exercise stress test for ischemia (<2 mm ST depression) at 1 week, and achieved >7 METs. Patients with left ventricular ejection fraction <40% were included only if they did not have inducible ventricular tachycardia at electrophysiologic studies. Seventy-two patients were randomized to return to normal activities at 2 weeks and 70 patients to undergo standard cardiac rehabilitation and return to normal activities at 6 weeks after AMI. There were no deaths or heart failure in either group. There was no significant difference in the incidence of reinfarction, revascularization, left ventricular function, lipids, body mass index, smoking, or exercise test results at 6 months. In conclusion, return to full normal activities, including work at 2 weeks, after AMI appears to be safe in patients who are stratified to a low-risk group. This should have significant medical and socioeconomic implications.