Impact of same-admission percutaneous coronary intervention on periprocedural outcomes of transcatheter aortic valve implantation.

Background: Current guidelines recommend percutaneous coronary intervention (PCI) prior to transcatheter aortic valve implantation (TAVI) if significant coronary artery disease is present, but whether PCI should be done in the same admission as TAVI is not determined. Methods: We retrospectively analyzed the National Inpatient Sample from 2016 to 2019 to compare TAVI with and without same-admission PCI and compare in-hospital outcomes after propensity score matching. Results: Among 170,030 hospitalizations for TAVI, 4425 (2.6%) had same-admission PCI performed. After propensity score matching, 4425 hospitalizations were allocated to those with and without same-admission PCI. No difference in in-hospital mortality (odds ratio [OR] 1.59, 95% confidence interval [CI] 0.81-3.12) was observed between the two groups. However, TAVI with same-admission PCI was associated with higher odds of cardiac arrest (OR 2.25, 95% CI 1.02-4.98), cardiogenic shock (OR 2.21, 95% CI 1.29-3.79), and acute myocardial infarction (OR 3.23, 95% CI 2.11-4.93). It was also associated with longer length of stay and more expensive hospital cost. Conclusion: TAVI with same-admission PCI was associated with higher odds of periprocedural complications and higher immediate cost. Our findings should be interpreted in the context of the same-admission PCI and TAVI cohort potentially being sicker and the isolated TAVI control group may or may not having obstructive coronary artery disease.

Comparison of intravascular ultrasound, optical coherence tomography, and conventional angiography-guided percutaneous coronary interventions: A systematic review, network meta-analysis, and meta-regression.

BACKGROUND: Intracoronary imaging modalities, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), provide valuable supplemental data unavailable on coronary angiography (CA) and have shown to improve clinical outcomes. We sought to compare the clinical efficacy of IVUS, OCT, and conventional CA-guided percutaneous coronary interventions (PCI). METHODS: Frequentist and Bayesian network meta-analyses of randomized clinical trials were performed to compare clinical outcomes of PCI performed with IVUS, OCT, or CA alone. RESULTS: A total of 28 trials comprising 12,895 patients were included. IVUS when compared with CA alone was associated with a significantly reduced risk of major adverse cardiovascular events (MACE) (risk ratio: [RR] 0.74, 95% confidence interval: [CI] 0.63-0.88), cardiac death (RR: 0.64, 95% CI: 0.43-0.94), target lesion revascularization (RR: 0.68, 95% CI: 0.57-0.80), and target vessel revascularization (RR: 0.64, 95% CI: 0.50-0.81). No differences in comparative clinical efficacy were found between IVUS and OCT. Rank probability analysis bestowed the highest probability to IVUS in ranking as the best imaging modality for all studied outcomes except for all-cause mortality. CONCLUSION: Compared with CA, the use of IVUS in PCI guidance provides significant benefit in reducing MACE, cardiac death, and revascularization. OCT had similar outcomes to IVUS, but more dedicated studies are needed to confirm the superiority of OCT over CA.

Chronological comparison of TAVI and SAVR stratified to surgical risk: a systematic review, meta-analysis, and meta-regression.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been established as a reasonable alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis. However, long-term outcomes including valve durability and the need for reintervention are unanswered, especially in younger patients who tend to be low surgical risk. We performed a meta-analysis comparing clinical outcomes after TAVI and SAVR over 5 years stratified to low, intermediate, and high surgical risks. METHODS: We identified propensity score-matched observational studies and randomised controlled trials comparing TAVI and SAVR. Primary outcomes, including all-cause mortality, moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, pacemaker placement, and stroke, were extracted. Meta-analyses of outcomes after TAVI compared to SAVR were conducted for different periods of follow-up. Meta-regression was also performed to analyse the correlation of outcomes over time. RESULTS: A total of 36 studies consisting of 7 RCTs and 29 propensity score-matched studies were selected. TAVI was associated with higher all-cause mortality at 4-5 years in patients with low or intermediate surgical risk. Meta-regression time demonstrated an increasing trend in the risk of all-cause mortality after TAVI compared with SAVR. TAVI was generally associated with a higher risk of moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, and pacemaker placement. CONCLUSIONS: TAVI demonstrated an increasing trend of all-cause mortality compared with SAVR when evaluated over a long-term follow-up. More long-term data from recent studies using newer-generation valves and state-of-the-art techniques are needed to accurately assign risks.

Transcatheter aortic valve implantation (TAVI) was associated with increased all-cause mortality at longer periods of follow-up irrespective of surgical risk. Aortic regurgitation, paravalvular regurgitation, major vascular complications, and pacemaker placement favoured surgical aortic valve replacement (SAVR) over TAVI. TAVI remained superior to SAVR in major bleeding and renal failure events. Long-term data on newer generation valves and up-to-date implantation techniques may provide better durability and improved outcomes after TAVI.

Impact of cardiac and noncardiac cirrhosis on coronary revascularization outcomes from the National Inpatient Sample, 2016 to 2018.

Data on coronary revascularization in patients with cirrhosis are scarce because it is often deferred in the setting of significant comorbidities and coagulopathies. It is unknown whether patients with cardiac cirrhosis have a worse prognosis. The National Inpatient Sample was surveyed to identify patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) from 2016 to 2018. Those with and without liver cirrhosis were propensity score-matched and compared within the PCI and CABG cohorts. Primary outcome was in-hospital mortality. Patients with cirrhosis were further classified into cardiac and noncardiac cirrhosis and their in-hospital mortalities were compared. A total of 1,069,730 PCIs and 273,715 CABGs were performed for ACS, of which 0.6% and 0.7%, respectively, were performed in patients with cirrhosis. In both the PCI cohort (odds ratio = 1.56; 95% confidence interval, 1.10-2.25; P = 0.01) and the CABG cohort (odds ratio = 2.34; 95% confidence interval, 1.19-4.62; P = 0.01), cirrhosis was associated with higher in-hospital mortality. In-hospital mortality was greatest in cardiac cirrhosis (8.4% and 7.1%), followed by noncardiac cirrhosis (5.5% and 5.0%) and no cirrhosis (2.6% and 2.3%) in PCI and CABG cohorts, respectively. Higher in-hospital mortality and periprocedural morbidities should be considered when performing coronary revascularization in patients with cirrhosis.

Trends and impact of intravascular ultrasound and optical coherence tomography on percutaneous coronary intervention for myocardial infarction.

Background: Intravascular imaging with either intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during percutaneous coronary intervention (PCI) is associated with improved outcomes, but these techniques have previously been underutilized in the real world. We aimed to examine the change in utilization of intravascular imaging-guided PCI over the past decade in the United States and assess the association between intravascular imaging and clinical outcomes following PCI for myocardial infarction (MI). Methods: We surveyed the National Inpatient Sample from 2008 to 2019 to calculate the number of PCIs for MI guided by IVUS or OCT. Temporal trends were analyzed using Cochran-Armitage trend test or simple linear regression for categorical or continuous outcomes, respectively. Multivariable logistic regression was used to compare outcomes following PCI with and without intravascular imaging. Results: A total of 2,881,746 PCIs were performed for MI. The number of IVUS-guided PCIs increased by 309.9 % from 6,180 in 2008 to 25,330 in 2019 (P-trend < 0.001). The percentage of IVUS use in PCIs increased from 3.4 % in 2008 to 8.7 % in 2019 (P-trend < 0.001). The number of OCT-guided PCIs increased 548.4 % from 246 in 2011 to 1,595 in 2019 (P-trend < 0.001). The percentage of OCT guidance in all PCIs increased from 0.0 % in 2008 to 0.6 % in 2019 (P-trend < 0.001). Intravascular imaging-guided PCI was associated with lower odds of in-hospital mortality (adjusted odds ratio 0.66, 95 % confidence interval 0.60-0.72, p < 0.001). Conclusions: Although the number of intravascular imaging-guided PCIs have been increasing, adoption of intravascular imaging remains poor despite an association with lower mortality.

Factor Xa inhibitors versus vitamin K antagonist in morbidly obese patients with venous thromboembolism: a systematic review and meta-analysis.

INTRODUCTION: Guidelines have endorsed non-vitamin K antagonist oral anticoagulants (NOACs), consisting of factor Xa inhibitors (xabans) and direct thrombin inhibitors, as the first line of treatment in venous thromboembolism (VTE) and atrial fibrillation. However, morbidly obese patients were under-represented in landmark trials of NOACs. Therefore, this study aimed to systematically review and perform a meta-analysis of studies on xabans versus vitamin K antagonist (VKA) in this high-risk population with VTE. METHODS: PubMed, Embase, Medline, Cochrane library, and Google Scholar databases were searched to identify studies that compared xabans and VKA in treating morbidly obese patients with VTE. Morbid obesity was defined as body weight ≥ 120 kg or BMI ≥ 40 kg/m2. Outcomes of interest included recurrent VTE, major bleeding, and clinically relevant non-major bleeding (CRNMB). RESULTS: Eight studies comprising 30,895 patients were included. A total of 12,755 patients received xabans while 18,140 received VKAs. No significant difference in the odds of recurrent VTE (OR 0.75, 95% CI 0.55-1.01) and CRNMB (OR 0.69, 95% CI 0.44-1.09) was observed between the xabans group and the VKA group. However, the xabans group was associated with lower odds of major bleeding (OR 0.70, 95% CI 0.59-0.83). CONCLUSION: Xabans have lower odds of major bleeding but similar odds of recurrent VTE when compared with VKAs in treating VTE in morbidly obese patients. Large registry analyses or future randomized controlled trials will be helpful in confirming these findings.

Network Meta-Analysis Comparing Angiotensin Receptor-Neprilysin Inhibitors, Angiotensin Receptor Blockers, and Angiotensin-Converting Enzyme Inhibitors in Heart Failure With Reduced Ejection Fraction.

The superiority of angiotensin receptor-neprilysin inhibitor (ARNI) over angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin receptor blocker (ARB) has not been reassessed after the publication of recent trials that did not find clinical benefits. Therefore, we performed an updated network meta-analysis comparing the efficacy and safety of ARNI, ACE-I, ARB, and placebo in heart failure with reduced ejection fraction. We included randomized clinical trials that compared ARNI, ARB, ACE-I, and placebo in heart failure with reduced ejection fraction. We extracted prespecified efficacy end points and produced network estimates, p scores, and surface under the cumulative ranking curve scores using frequentist and Bayesian network meta-analysis approaches. A total of 28 randomized controlled trials including 47,407 patients were included. ARNI was associated with lower risk of all-cause mortality (relative risk [RR] 0.81, 95% confidence interval [CI] 0.68 to 0.96), cardiac death (RR 0.79, 95% CI 0.64 to 0.99), and major adverse cardiac events (MACEs; RR 0.83, 95% CI 0.72 to 0.97) but higher risk of hypotension (RR 1.46, 95% CI 1.02 to 2.10) than ARB. ARNI was associated with lower risk of MACE (RR 0.85, 95% CI 0.74 to 0.97), but higher risk of hypotension (RR 1.69, 95% CI 1.27 to 2.24) compared with ACE-I. P scores and surface under the cumulative ranking curve scores demonstrated superiority of ARNI over ARB and ACE-I in all-cause mortality, cardiac death, MACE, and hospitalization for heart failure. In conclusion, ARNI was associated with improved clinical outcomes, except for higher risk of hypotension, compared with ARB and ACE-I.

Projection of Cancer Incidence and Mortality From 2020 to 2035 in the Korean Population Aged 20 Years and Older.

OBJECTIVES: This study aimed to identify the current patterns of cancer incidence and estimate the projected cancer incidence and mortality between 2020 and 2035 in Korea. METHODS: Data on cancer incidence cases were extracted from the Korean Statistical Information Service from 2000 to 2017, and data on cancer-related deaths were extracted from the National Cancer Center from 2000 to 2018. Cancer cases and deaths were classified according to the International Classification of Diseases, 10th edition. For the current patterns of cancer incidence, age-standardized incidence rates (ASIRs) and age-standardized mortality rates were investigated using the 2000 mid-year estimated population aged over 20 years and older. A joinpoint regression model was used to determine the 2020 to 2035 trends in cancer. RESULTS: Overall, cancer cases were predicted to increase from 265 299 in 2020 to 474 085 in 2035 (growth rate: 1.8%). The greatest increase in the ASIR was projected for prostate cancer among male (7.84 vs. 189.53 per 100 000 people) and breast cancer among female (34.17 vs. 238.45 per 100 000 people) from 2000 to 2035. Overall cancer deaths were projected to increase from 81 717 in 2020 to 95 845 in 2035 (average annual growth rate: 1.2%). Although most cancer mortality rates were projected to decrease, those of breast, pancreatic, and ovarian cancer among female were projected to increase until 2035. CONCLUSIONS: These up-to-date projections of cancer incidence and mortality in the Korean population may be a significant resource for implementing cancer-related regulations or developing cancer treatments.

Association of metabolic comorbidity with myocardial infarction in individuals with a family history of cardiovascular disease: a prospective cohort study.

BACKGROUND: The association between metabolic comorbidity and myocardial infarction (MI) among individuals with a family history of cardiovascular disease (CVD) is yet to be elucidated. We aimed to examine the combined effects of metabolic comorbidities, including diabetes mellitus, hypertension, and dyslipidemia, with a family history of CVD in first-degree on the risk of incident MI. METHODS: This cohort study consisted of 81,803 participants aged 40-89 years without a previous history of MI at baseline from the Korean Genome and Epidemiology Study. We performed Cox proportional hazard regression analysis to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for MI and early-onset MI risk associated with metabolic comorbidity in individuals with a family history of CVD. RESULTS: During a median follow-up of 5 years, 1,075 and 479 cases of total and early-onset MI were reported, respectively. According to the disease score, among individuals who had a positive family history of CVD, the HRs for MI were 1.92 (95% CI: 1.47-2.51) in individuals with one disease, 2.75 (95% CI: 2.09-3.61) in those with two diseases, and 3.74 (95% CI: 2.45-5.71) in those with three diseases at baseline compared to individuals without a family history of CVD and metabolic diseases. Similarly, an increase of the disease score among individuals with a positive family history of CVD was associated with an increase in early-onset MI risk. CONCLUSION: Metabolic comorbidity was significantly associated with an increased risk of MI among individuals with a family history of CVD.

Readmission rates and risk factors for readmission after transcatheter aortic valve replacement in patients with end-stage renal disease.

OBJECTIVES: We sought to examine readmission rates and predictors of hospital readmission following TAVR in patients with ESRD. BACKGROUND: End-stage renal disease (ESRD) is associated with poor outcomes following transcatheter aortic valve replacement (TAVR). METHODS: We assessed index hospitalizations for TAVR from the National Readmissions Database from 2017 to 2018 and used propensity scores to match those with and without ESRD. We compared 90-day readmission for any cause or cardiovascular cause. Length of stay (LOS), mortality, and cost were assessed for index hospitalizations and 90-day readmissions. Multivariable logistic regression was performed to identify predictors of 90-day readmission. RESULTS: We identified 49,172 index hospitalizations for TAVR, including 1,219 patients with ESRD (2.5%). Patient with ESRD had higher rates of all-cause readmission (34.4% vs. 19.2%, HR 1.96, 95% CI 1.68-2.30, p<0.001) and cardiovascular readmission (13.2% vs. 7.7%, HR 1.85, 95% CI 1.44-2.38, p<0.001) at 90 days. During index hospitalization, patients with ESRD had longer length of stay (mean difference 1.9 days), increased hospital cost (mean difference $42,915), and increased in-hospital mortality (2.6% vs. 0.9%). Among those readmitted within 90 days, patients with ESRD had longer LOS and increased hospital charge, but similar in-hospital mortality. Diabetes (OR 1.86, 95% CI 1.31-2.64) and chronic pulmonary disease (OR 1.51, 95% CI 1.04-2.18) were independently associated with higher odds of 90-day readmission in patients with ESRD. CONCLUSION: Patients with ESRD undergoing TAVR have higher mortality and increased cost associated with their index hospitalization and are at increased risk of readmission within 90 days following TAVR.

Impact of end-stage renal disease on in-hospital outcomes of hypertensive emergency from the National Inpatient Sample, 2016 to 2018.

The prevalence and incidence of end-stage renal disease (ESRD) has been increasing. However, data on inpatient outcomes of hypertensive emergencies in patients with ESRD are lacking. We performed a retrospective study using the largest inpatient database in the United States. Hospitalizations for hypertensive emergency between 2016 and 2018 were identified from the National Inpatient Sample. Propensity score matching was performed between those with and without ESRD. The primary outcome was in-hospital mortality, and secondary outcomes included end-organ complications of hypertensive emergency. Multivariable logistic regression was used to identify potential risk factors of in-hospital mortality. Of 105,565 hospitalizations for hypertensive emergency, 15% occurred in patients with ESRD. Hospitalizations for hypertensive emergency in patients with ESRD were associated with higher odds of cardiac arrest (odds ratio [OR] 4.52, 95% confidence interval [CI] 1.53-13.3, P = 0.01) and acute pulmonary edema (OR 2.80, 95% CI 2.15-3.65, P < 0.01) and a longer hospital stay (mean difference 1.15 days, 95% CI 0.88-1.43, P < 0.01). Age ≥65 years, obesity, atrial fibrillation, and malnutrition were associated with higher odds of in-hospital mortality. Our findings demonstrate the excess morbidities in patients with ESRD admitted for hypertensive emergency.

National trend of heart failure and other cardiovascular diseases in people living with human immunodeficiency virus.

BACKGROUND: As people living with human immunodeficiency virus (HIV) (PLWH) enjoy longer life expectancy with highly effective antiretroviral therapy, they are encountering challenging cardiovascular health risks. AIM: To retrospectively examine the increasing burden of cardiovascular diseases in PLWH over the past decade. METHODS: All hospitalizations for heart failure (HF), ischemic heart disease (IHD), and cerebrovascular disease (CeVD) in PLWH were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM codes in the National Inpatient Sample from 2008 to 2018. Outcomes included number of hospitalizations, in-hospital mortality, length of stay, and total hospital charge. Trend of the outcomes from 2008 to 2018 were analyzed using Cochran-Armitage trend test and simple linear regression. RESULTS: The number of hospitalizations for HF in PLWH increased from 4212 in 2008 to 6700 in 2018 (P trend < 0.01). Similar increasing trend was seen with those for IHD and CeVD over the decade (P trend < 0.01). A decreasing trend of in-hospital mortality was observed in all hospitalizations of PLWH (P trend < 0.01) and CeVD in PLWH (P trend < 0.01), but not in those for HF (P trend = 0.67) and IHD (P trend = 0.13). The trend of length of stay was decreasing in all hospitalizations of PLWH (P trend < 0.01), but increasing in those for HF in PLWH (P trend < 0.01). An increasing trend of total hospital charge was observed in hospitalizations for HF, IHD, and CeVD (P trend < 0.01). CONCLUSION: The burden of cardiovascular diseases has significantly increased in hospitalizations of PLWH from 2008 to 2018. Continued efforts are needed to address the additional cardiovascular risks in this vulnerable population.

Abbreviated versus Standard Duration of DAPT after PCI: A Systematic Review and Network Meta-analysis.

BACKGROUND: Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) is typically continued for 6-12 months depending on clinical presentation. Recent studies have evaluated the safety of shorter durations of DAPT across stable and unstable coronary syndrome but are limited by smaller patient pools and varying indications. METHODS: The present study performed a systematic review and network meta-analysis comparing abbreviated (1-3 months) with standard (6-12 months) duration of DAPT. Both conventional and frequentist network meta-analyses with a random-effects model were conducted. RESULTS: Seventeen randomized controlled trials, nine of which included 1-3 months of DAPT, were selected. The risks of any bleeding (RR 0.68, 95% CI 0.54-0.85), major bleeding (RR 0.66, 95% CI 0.50-0.86), and net adverse clinical events (NACE) (RR 0.87, 95% CI 0.76-0.99) were lower with abbreviated (1-3 months) than standard-term (6-12 months) DAPT. No significant differences in the risk of myocardial infarction (RR 1.02, 95% CI 0.87-1.18), definite or probable stent thrombosis (RR 1.11, 95% CI 0.83-1.50), and major adverse cardiac events (MACE) (RR 0.96, 95% CI 0.86-1.06) were observed. Network meta-analysis demonstrated lower risk of any bleeding, major bleeding, and NACE with shorter durations of DAPT compared with 12 months. Risks of definite or probable stent thrombosis, myocardial infarction, and MACE were not significantly different. CONCLUSION: The results support the growing body of evidence that abbreviated duration (1-3 months) of DAPT may be considered to reduce the risk of bleeding without any differences in myocardial infarction, stent thrombosis, or MACE.

Modified reverse shock index predicts early outcomes of heart failure with reduced ejection fraction.

AIMS: Increased blood pressure (BP) and decreased heart rate (HR) are signs of stabilization in patients admitted for acute HF. Changes in BP and HR during admission and their correlation with outcomes were assessed in hospitalized patients with heart failure (HF) with reduced ejection fraction (HFrEF). METHODS: A novel modified reverse shock index (mRSI), defined as the ratio between changes in systolic BP and HR during admission, was devised, and its prognostic value in the early outcomes of acute HF was assessed using the Korean Acute HF registry. RESULTS: Among 2697 patients with HFrEF (mean age 65.8 ± 14.9 years, 60.6% males), patients with mRSI ≥1.25 at discharge were significantly younger and were more likely to have de novo HF. An mRSI ≥1.25 was associated with a significantly lower incidence of 60-day and 180-day all-cause mortality [hazard ratio (HR) 0.49, 95% confidence interval (CI) 0.31-0.77; HR 0.62, 95% CI 0.45-0.85, respectively], compared with 1 ≤ mRSI < 1.25 (all P < 0.001). Conversely, an mRSI <0.75 was associated with a significantly higher incidence of 60-day and 180-day all-cause mortality (adjusted HR 2.08, 95% CI 1.19-3.62; HR 2.24, 95% CI 1.53-3.27; all P < 0.001). The benefit associated with mRSI ≥1.25 was consistent in sub-group analyses. The correlation of mRSI and outcomes were also consistent regardless of admission SBP, presence of atrial fibrillation, or use of beta blockers at discharge. CONCLUSIONS: In patients hospitalized for HFrEF, the mRSI was a significant predictor of early outcomes. The mRSI could be used as a tool to assess patient status and guide physicians in treating patients with HFrEF.

In-hospital prognosis of malignancy-related pulmonary embolism: an analysis of the national inpatient sample 2016-2018.

A substantial proportion of patients with malignancy develop pulmonary embolism (PE), which significantly worsens the prognosis and ranks as one of the leading causes of mortality in these patients. This retrospective study aimed to examine prognosis of PE in 17 different types of malignancies. All hospitalizations for a primary diagnosis of PE, were identified from the National Inpatient Sample from 2016 to 2018 and divided into those with and without malignancies. Propensity score matching was performed with malignancy as the dependent variable and 23 clinically relevant covariates. Malignancy was stratified into 17 different types of cancer, for which the odds of in-hospital mortality were calculated. After propensity score matching, 82,970 hospitalizations for PE each were allocated into those with and without malignancy groups. PE in all types of malignancies had significantly higher odds of in-hospital mortality compared to PE without malignancy (OR 2.27, 95% CI 2.03-2.54). When stratified to types, esophageal cancer (OR 4.05, 95% CI 2.77-5.92) was associated with the highest odds of in-hospital mortality, followed by gastric (OR 3.41, 95% CI 2.25-5.16) and ovarian cancer (OR 2.95, 95% CI 2.12-4.13). On sensitivity analysis, only PE in esophageal and lung cancer was associated with higher odds of in-hospital mortality compared to PE in all other malignancies combined. Hospitalizations for PE in patients with malignancy were associated with higher odds of in-hospital mortality than those without malignancy. Esophageal cancer had the highest odds of in-hospital mortality, followed by gastric, ovarian, and lung cancer.

Systematic Review and Network Meta-Analysis Comparing Bifurcation Techniques for Percutaneous Coronary Intervention.

Background Bifurcation lesions account for 20% of all percutaneous coronary interventions and represent a complex subset which are associated with lower procedural success and higher rates of restenosis. The ideal bifurcation technique, however, remains elusive. Methods and Results Extensive search of the literature was performed to pull data from randomized clinical trials that met predetermined inclusion criteria. Conventional meta-analysis produced pooled relative risk (RR) and 95% CI of 2-stent technique versus provisional stent on prespecified outcomes. Both frequentist and Bayesian network meta-analyses were performed to compare bifurcation techniques. A total of 8318 patients were included from 29 randomized clinical trials. Conventional meta-analysis showed no significant differences in all-cause mortality, cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization between 2-stent techniques and provisional stenting. Frequentist network meta-analysis revealed that double kissing crush was associated with lower cardiac death (RR, 0.57; 95% CI, 0.38-0.84), major adverse cardiac events (RR, 0.50; 95% CI, 0.39-0.64), myocardial infarction (RR, 0.60; 95% CI, 0.39-0.90), stent thrombosis (RR, 0.50; 95% CI, 0.28-0.88), target lesion revascularization, and target vessel revascularization when compared with provisional stenting. Double kissing crush was also superior to other 2-stent techniques, including T-stent or T and protrusion, dedicated bifurcation stent, and culotte. Conclusions Double kissing crush was associated with lower risk of cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization compared with provisional stenting and was superior to other 2-stent techniques. Superiority of 2-stent strategy over provisional stenting was observed in subgroup meta-analysis stratified to side branch lesion length ≥10 mm.

Myocarditis after COVID-19 mRNA vaccination: A systematic review of case reports and case series.

BACKGROUND: The coronavirus disease of 2019 (COVID-19) is a global pandemic with over 266 million cases and 5 million deaths worldwide. Anti-COVID-19 vaccinations have had exceptional success in subduing the incidence, prevalence, and disease severity of COVID-19, but rare cases of myocarditis have been reported after COVID-19 vaccinations. HYPOTHESIS: Myocarditis occurring after COVID-19 mRNA vaccinations have distinguishable clinical characteristics. They usually have a favorable prognosis. METHODS: We performed a systematic literature search on PUBMED and MEDLINE database from inception to December 5, 2021. Studies were analyzed based on predetermined eligibility criteria. RESULTS: A total of 57 studies containing 275 cases of COVID-19 vaccine-associated myocarditis were catalogued. Mean age was 26.7 years and male to female ratio was 14:1. For 86.9% of patients, myocarditis occurred after the second dose. Average time to onset and length of hospitalization were 3.7 and 3.9 days, respectively. Prognosis was largely benign, but there was a 1.1% reported mortality. Chest pain (95.2%), elevation of troponin (100%), and ST elevation on electrocardiography (68.5%) were common. Nonsteroidal anti-inflammatory drugs (81.4%) were the most used medication, followed by colchicine (33.1%). CONCLUSIONS: Patients with COVID-19 vaccine-associated myocarditis are usually younger males presenting with chest pain 3-4 days after receiving their second dose of COVID vaccine. Diagnosis is made by exclusion of all other etiologies. Given significant population benefit from COVID-19 vaccination, physicians should continue to encourage vaccination while remaining vigilant of the very rare occurrence of myocarditis following COVID-19 vaccination.

Shortening the duration of dual antiplatelet therapy after percutaneous coronary intervention for acute coronary syndrome: A systematic review and meta-analysis.

INTRODUCTION: The decision to shorten the duration of DAPT following PCI in patients with ACS remains controversial because of the concern for increased ischemic events. METHODS: We performed a comprehensive literature search in seven databases to explore the efficacy of 1 to 3 months of DAPT in patients who underwent PCI for ACS. Randomized controlled trials that compared 1 to 3 months with 6 to 12 months of DAPT after PCI for ACS were identified. Integrated hazard ratio (HR) and 95% confidence interval (CI) were calculated by random effects model for each prespecified outcome of interest. Meta-regression analyses were performed to examine the association of outcomes with select patient characteristics. RESULTS: A total of 9 randomized controlled trials consisting of 25,907 patients were included. There was no difference in the hazard of NACE (HR 0.92, 95% CI 0.79-1.07) and MACE (HR 0.96, 95% CI 0.78-1.17) between 1 and 3 months of DAPT and 6 to 12 months of DAPT. However, implementing 1 to 3 months of DAPT was associated with lower hazard of both any bleeding (HR 0.55, 95% CI 0.46-0.66) and major bleeding (HR 0.47, 95% CI 0.36-0.62). Meta-regression revealed a nonsignificant but increasing trend of both NACE and MACE with greater proportion of left main and left anterior descending coronary artery lesions and greater proportion of STEMI included in the trials. CONCLUSION: Our findings suggest that 1 to 3 months of DAPT has similar efficacy for preventing ischemic events with reduced bleeding risk compared with 6 to 12 months of DAPT.

Binary cutpoint and the combined effect of systolic and diastolic blood pressure on cardiovascular disease mortality: A community-based cohort study.

OBJECTIVES: This study aimed to examine the risk of cardiovascular disease (CVD) death according to blood pressure levels and systolic and/or diastolic hypertension. METHODS: From 20,636 cohort participants, 14,375 patients were enrolled after patients with prior hypertension on antihypertensive drugs were excluded. For the combination analysis, participants were divided into four groups (systolic/diastolic hypertension, systolic hypertension only, diastolic hypertension only, and non-hypertension). The risk of CV death was calculated using the hazard ratio (HR) and 95% confidence intervals (95% CI) in a Cox regression model. RESULTS: The risk of CVD death increased in systolic hypertension (HR = 1.59, 95% CI 1.26-2.00) and systolic/diastolic hypertension (HR = 1.84, 95% CI 1.51-2.25). The highest risks of hemorrhagic and ischemic stroke were observed in the diastolic hypertension (HR = 4.11, 95% CI 1.40-12.06) and systolic/diastolic hypertension groups (HR = 2.59, 95% CI 1.92-3.50), respectively. The risk of CVD death was drastically increased in those with SBP≥120 mmHg/DBP≥80 mmHg. The highest risk was observed in those with SBP of 130-131 mmHg and 134-137 mmHg. CONCLUSION: The combined analysis of systolic and/or diastolic hypertension appears to be a good predictor of CVD death. The risk of CVD death in the prehypertensive group could be carefully monitored as well as in the hypertensive group, presumably due to less attention and the lack of antihypertensive treatment.