Comparison of on-treatment platelet reactivity between triple antiplatelet therapy with cilostazol and standard dual antiplatelet therapy in patients undergoing coronary interventions: a meta-analysis.

BACKGROUND: The recent literature has shown that triple antiplatelet therapy with cilostazol in addition to the standard dual antiplatelet therapy with aspirin and clopidogrel may reduce platelet reactivity and improve clinical outcomes following percutaneous coronary intervention. The purpose of this meta-analysis is to compare the efficacy of triple antiplatelet therapy and dual antiplatelet therapy in regard to on-treatment platelet reactivity. METHODS: Nine studies (n = 2179) comparing on-treatment platelet reactivity between dual antiplatelet therapy (n = 1193) and triple antiplatelet therapy (n = 986) in patients undergoing percutaneous coronary intervention were included. Primary end points were P2Y12 reaction unit (PRU) and platelet reactivity index (PRI). Secondary end points were platelet aggregation with adenosine diphosphate (ADP) 5 and 20 µmol/L and P2Y12% inhibition. Mean difference (MD) and 95% confidence intervals (CI) were computed and 2-sided α error <.05 was considered as a level of significance. RESULTS: Compared to dual antiplatelet therapy, triple antiplatelet therapy had significantly lower maximum platelet aggregation with ADP 5 µmol/L (MD: -14.4, CI: -21.6 to -7.2, P < .001) and 20 µmol/L (MD: -14.9, CI: -22.9 to -6.8, P < .001), significantly lower PRUs (MD: -45, CI: -59.4 to -30.6, P < .001) and PRI (MD: -26, CI: -36.8 to -15.2, P < .001), and significantly higher P2Y12% inhibition (MD: 18.5, CI: 2.3 to 34.6, P = .025). CONCLUSION: Addition of cilostazol to conventional dual antiplatelet therapy significantly lowers platelet reactivity and may explain a decrease in thromboembolic events following coronary intervention; however, additional studies evaluating clinical outcomes will be helpful to determine the benefit of triple antiplatelet therapy.

A meta-analysis of mortality and major adverse cardiovascular and cerebrovascular events following transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis.

The purpose of this meta-analysis was to compare postprocedural mortality and major adverse cardiovascular and cerebrovascular events between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) for severe aortic stenosis. Seventeen studies (n = 4,659) comparing TAVI (n = 2,267) and SAVR (n = 2,392) were included. End points were baseline logistic European System for Cardiac Operative Risk Evaluation score, all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, transient ischemic attack, and major bleeding events. Mean differences or risk ratios with 95% confidence intervals were computed, and p values <0.05 were considered significant. The population was matched for risk between the 2 groups on the basis of logistic European System for Cardiac Operative Risk Evaluation score for all outcomes except 30-day all-cause mortality, which had a high-risk population in the TAVI group (p = 0.02). There was no significant difference found in all-cause mortality at 30 days (p = 0.97) and at an average of 85 weeks (p = 0.07). There was no significant difference in cardiovascular mortality (p = 0.54) as well as the incidence of myocardial infarction (p = 0.59), stroke (p = 0.36), and transient ischemic attack (p = 0.85) at averages of 86, 72, 66, and 89 weeks, respectively. Compared with patients who underwent TAVI, those who underwent SAVR had a significantly higher frequency of major bleeding events (p <0.0001) at mean follow-up of 66 weeks. In conclusion, TAVI has similar cardiovascular and all-cause mortality to SAVR at early and long-term follow-up. TAVI is superior to SAVR for major bleeding complications and noninferior to SAVR for postprocedural myocardial infarctions and cerebrovascular events. TAVI is a safe alternative to SAVR in selected high-risk elderly patients with severe aortic stenosis.

Rare case of "wandering artery of drummond" as a result of chronic triple mesenteric vessel occlusion treated by isolated angioplasty and stenting of the inferior mesenteric artery.

We report a rare clinical scenario of chronic mesenteric ischemia (CMI) patient with obstruction of all the three major gut vessels including celiac, superior mesenteric artery (SMA), and inferior mesenteric artery (IMA) with a sole artery supplying the collaterals through marginal artery of left colon (the "wandering artery of Drummond"). A 70-year-old man was presented to hospital with acute onset of dyspnea, diaphoresis, severe epigastric pain, nausea, and vomiting that started after lunch. Initially, patient was diagnosed and treated for non-ST elevation myocardial infarction (NSTEMI). Furthermore, work-up, including computed tomographic scan of abdomen followed by angiogram, revealed 100% obstruction of celiac and SMA, whereas inferior IMA had 90% ostial lesion with poststenotic dilatation and collaterals supplying to entire colon. Subsequently, IMA ostial lesion was stented through percutaneous intervention and patient noted significantly improved symptoms and quality of life. To conclude, percutaneous endovascular treatments confer favorable strategy for CMI, and it may either be curative or allow nutritional optimization before definitive surgery.

CYP2C19*2/ABCB1-C3435T polymorphism and risk of cardiovascular events in coronary artery disease patients on clopidogrel: is clinical testing helpful?

BACKGROUND: Studies evaluating CYP2C19*2 and ABCB1-C3435T polymorphisms have shown conflicting results. We performed this meta-analysis to evaluate role of clinical testing for these polymorphisms in CAD patients on clopidogrel. METHODS: 19,601 patients from 14 trials were analyzed. The endpoints were major adverse cardiovascular events (MACE), cardiovascular (CV) death, stent thrombosis (ST), myocardial infarction (MI), stroke and major bleeding. Combined relative risks (RR) with 95% confidence intervals (CI) were computed for each outcome by using standard methods of meta-analysis and test parameters were computed. RESULTS: CYP2C19*2 polymorphism was associated with higher risk of MACE [RR: 1.28, CI: 1.06-1.54; p=0.009], CV death [RR: 3.21, CI: 1.65-6.23; p=0.001], MI [RR: 1.36, CI: 1.12-1.65; p=0.002], ST [RR: 2.41, CI: 1.69-3.41; p<0.001]. No difference was seen in major bleeding events [RR: 1.02, CI: 0.86-1.20; p=0.83]. Subgroup analysis showed similar results for elective PCI [RR: 1.34, CI: 1.01-1.76; p=0.03], and PCI with DES [RR: 1.53, CI: 1.029-1.269; p=0.03]. CYP2C19*2 polymorphism has very low sensitivity (28-58%), specificity (71-73%), positive predictive value (3-10%) but good negative predictive value (92-99%). ABCB1-C3435T polymorphism analysis revealed similar MACE [RR: 1.13, CI: 0.99-1.29; p=0.06], ST [RR: 0.88, CI: 0.52-1.47; p=0.63] and major bleeding [RR: 1.04, CI: 0.87-1.25; p=0.62] in both groups. CONCLUSION: In CAD patients on clopidogrel therapy, CYP2C19*2 polymorphism is associated with significantly increased adverse cardiovascular events. However, due to the low positive predictive value, routine genetic testing cannot be recommended at present.

Safety and efficacy of intracoronary adenosine administration in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: a meta-analysis of randomized controlled trials.

BACKGROUND: Studies evaluating intracoronary administration of adenosine for prevention of microvascular dysfunction and ischemic-reperfusion injury in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) have yielded mixed results. Therefore, we performed a meta-analysis of these trials to evaluate the safety and efficacy of intracoronary adenosine administration in patients with AMI undergoing primary PCI. METHODS: A total of seven prospective randomized controlled trials were analyzed. The endpoints extracted were post-procedure residual stent thrombosis (ST) segment elevation and ST segment resolutions (STRes), difference in peak creatine kinase (CK-MB) concentration, thrombolysis in myocardial infarction (TIMI) grade III flow (TIMI 3 flow), myocardial blush grade (MBG) 3, mean difference in post-PCI ejection fraction (EF), all-cause mortality, cardiovascular mortality, heart failure (HF) and major adverse cardiovascular event (MACE). Safety endpoints analyzed were bradycardia, second-degree atrioventricular block (AVB), ventricular tachycardia (VT), ventricular fibrillation (VF) and recurrence of chest pain (CP). The endpoints were analyzed by standard methods of meta-analysis. RESULTS: Intracoronary adenosine therapy led to significantly more post-PCI STRes [relative risk (RR) 1.39, 95% confidence interval (CI) 1.01-1.90; p = 0.04] and reduction in residual ST segment elevation (RR 0.82, CI 0.69-0.99; p = 0.04) but did not improve TIMI 3 flow (RR 1.09, CI 0.94-1.27; p = 0.25), MBG3 (RR 1.04, CI 0.65-1.69; p = 0.88), peak CK-MB concentration (mean difference -39.43, CI -120.223 to 41.371; p = 0.339) and post-PCI EF (mean difference 1.238, CI -5.802 to 8.277; p = 0.730). There was a trend towards improvement and MACE (RR 0.64, CI 0.40-1.03; p = 0.06), incidence of HF (RR 0.47, CI 0.19-1.12; p = 0.08) and CV mortality (RR 0.15, CI 0.02-1.23; p = 0.08) that did not reach statistical significance but no difference in all-cause mortality (RR 0.77, CI 0.25-2.34; p = 0.64). Safety analysis showed no significant difference in CP events (RR 1.26, CI 0.55-2.86; p = 0.58), bradycardia (RR 2.19, CI 0.24-0.38; p = 0.49), VT (odds ratio 0.61, CI 0.08-4.90; p = 0.64) and VF (RR 0.49, CI 0.13-1.90; p = 0.30), but significantly more second-degree AVB (RR 7.88, CI 4.15-14.9; p < 0.01) in the adenosine group compared with the placebo group. CONCLUSION: Intracoronary adenosine administration was well tolerated and significantly improved electrocardiographic outcomes with a tendency towards improvement in MACE, HF and CV mortality that could not reach statistical significance.

Safety and efficacy of transradial versus transfemoral percutaneous coronary intervention in acute myocardial infarction: a meta-analysis of randomized trials.

BACKGROUND: The transradial approach has gained increasing popularity for elective percutaneous coronary intervention. However, the safety and feasibility of transradial coronary intervention (TRI) in acute myocardial infarction (AMI) remains uncertain. Hence, a meta-analysis of randomized trials was performed to compare outcomes of TRI with transfemoral coronary intervention (TFI) in patients with AMI. METHODS: A systematic review of the literature revealed seven randomized trials involving 1306 patients. Endpoints extracted were access site complications, major adverse cardiovascular events, major bleeding, and procedural success. Combined relative risks (RRs) across all studies and 95% confidence intervals (CIs) were computed. A two-sided α error of less than 0.05 was considered to be statistically significant. RESULTS: Baseline characteristics were similar in both groups. Compared with patients undergoing TFI, risk of major adverse cardiovascular events (RR: 0.83, CI: 0.51-1.35; P=0.45) and major bleeding (RR: 0.51, CI: 0.20-1.26; P=0.14) was similar in patients undergoing TRI. The procedural success was similar with both approaches (RR: 0.99, CI: 0.96-1.02; P=0.59). However, incidence of access site complications was significantly lower in the TRI group (RR: 0.31, CI: 0.17-0.58; P<0.001). CONCLUSION: The meta-analysis suggests that TRI may be superior to TFI in reducing access site complications in patients with AMI. However, there is no difference in procedural success and major bleeding between the two groups.