Sex-based outcomes of surgical myectomy for hypertrophic cardiomyopathy: An analysis from the National Readmission Database.

BACKGROUND: There is a paucity of data on sex differences in outcomes after surgical myectomy (SM) for hypertrophic cardiomyopathy (HCM). METHODS: Patients who received SM for HCM during October 1, 2015, through December 31, 2018, were identified from the US National Readmission Database. The primary end point of this study was in-hospital mortality. The secondary end points were major bleeding, acute kidney injury, new pacemaker implantation, severe disability surrogates (non-home discharge and need for mechanical ventilation), resources utilization surrogates (length of stay and cost of hospitalization), and 30-day outcomes (readmission rate, mortality, and new pacemaker insertion). RESULTS: A total of 3031 patients were included in the current analysis. Using propensity score matching, 2 well matched cohorts were compared (women = 1170 and men = 1127). Women had a higher requirement for new pacemaker insertion compared with men (10.9% vs 6.8%; P = .029), higher number of non-home discharges (13.8% vs 7.9%; P < .01), and longer length of hospital stay (median = 7 [interquartile range, 5-9] days) versus (median = 6 [interquartile range, 5-8] days). There was no difference in in-hospital mortality, major bleeding, blood transfusion, acute kidney injury, or hospitalization costs for women versus men. At 30 days, women continued to show a higher need for pacemaker insertion (11.3% vs 7.1%; P = .03) and had a higher readmission rate than men (10.9% vs 7.1%; P = .02). There was no difference in 30-day mortality between women and men (3% vs 2.4%; P = .54). CONCLUSIONS: Among the HCM cohort who received SM, significant sex-based differences in the outcomes were observed. Women had higher new pacemaker insertion rate, higher non-home discharge rate, and higher rate of 30-day readmission compared with men.

Association Between Breast Arterial Calcification on Mammography and Coronary Artery Disease: A Systematic Review and Meta-Analysis.

Background: Breast arterial calcification (BAC), which may be detected during screening mammography, is hypothesized to be a noninvasive imaging marker that may enhance cardiovascular risk assessment. Materials and Methods: In this systematic review and meta-analysis, we sought to assess the association between BAC and coronary artery disease (CAD) by conducting a meta-analysis. We conducted a literature search of PubMed, Scopus, Cochrane library, ClinicalTrials.gov, and conference proceedings, from inception through December 24, 2019. The outcome of interest was the presence of CAD in patients with BAC. This was reported as crude and adjusted odds ratio (OR). Results: A total of 18 studies comprising 33,494 women (mean age of 60.8 ± 3.7 years, 25% with diabetes, 57% with hypertension, and 21% with history of tobacco smoking) were included in the current meta-analysis. The prevalence of BAC among study participants was 10%. There was a statistically significant association between BAC and CAD (unadjusted OR 2.14; 95% confidence interval [CI] 1.63-2.81, p < 0.001, I2 = 76.5%). Moreover, adjusted estimates were available from 10 studies and BAC was an independent predictor of CAD (OR 2.39; 95% CI 1.68-3.41, p < 0.001, I2 = 61.7%). In the meta-regression analysis, covariates included year of publication, age, hypertension, diabetes mellitus, and history of tobacco smoking. None of these study covariates explained the heterogeneity across studies. Conclusions: BAC detected as part of screening mammography is a promising noninvasive imaging marker that may enhance CAD risk prediction in women. The clinical value of BAC for cardiovascular risk stratification merits further evaluation in large prospective studies.

Gender-based outcomes of coronary bifurcation stenting: A report from the National Readmission Database.

BACKGROUND: There is a paucity of data focusing on women's outcomes after percutaneous coronary interventions (PCI) for coronary bifurcation lesions (CBLs). METHODS: Patients who received PCI for CBLs in the context of acute coronary syndrome (ACS) during the period of 01 October 2015- 31 December 2017, were identified from the United States National Readmission Database. The primary endpoint of this study was in-hospital major adverse events (MAEs). The secondary endpoints were in-hospital mortality, vascular complications, major bleeding, post-procedural bleeding, need for blood transfusion, severe disability surrogates (non-home discharge and need for mechanical ventilation), resources utilization surrogates (length of stay and cost of hospitalization), and 30-day readmission rate. A 1:1 propensity score matching was used to compare the outcomes between women and men. RESULTS: A total of 25,050 (women = 7,480; men = 17,570) patients were included in the current analysis. After propensity score matching, women had higher in-hospital MAEs (7 vs 5.2%, p < .01), major bleeding (1.8 vs 0.8%, p < .01), post-procedural bleeding (6.1 vs 3.4%, p < .01), need for blood transfusion (6.4 vs 4.2%, p < .01), non-home discharges (10.2 vs 7.1%; p < .01), longer length of hospital stay (3 days [IQR 2-6] vs. 3 days [IQR 2-5], p < .01) and higher 30-day readmission rate compared to men (14.2 vs. 11.5%, p < .01). CONCLUSIONS: Among all-comers who received PCI for CBLs in the context of ACS, women suffered higher MAEs and 30-day readmission rates compared to their men' counterparts. The higher MAEs in the women were mainly driven by higher postprocedural bleeding rates and the need for blood transfusion.

Induced Hypothermia in Patients with Cardiac Arrest and a Non-shockable Rhythm: Meta-analysis and Trial Sequential Analysis.

BACKGROUND: Controversy surrounds utilization of induced hypothermia (IHT) in comatose cardiac arrest (CA) survivors with a non-shockable rhythm. METHODS: We conducted a meta-analysis and trial sequential analysis (TSA) comparing IHT with no IHT approaches in patients with CA and a non-shockable rhythm. The primary outcome of interest was favorable neurological outcomes (FNO) defined using the Cerebral Performance Category (CPC) score of 1 or 2. Secondary endpoints were survival at discharge and survival beyond 90 days. RESULTS: A total of 9 studies with 10,386 patients were included. There was no difference between both groups in terms of FNO (13% vs. 13%, RR 1.34, 95% CI 0.96-1.89, p = 0.09, I2 = 88%), survival at discharge (20% vs. 22%, RR 1.09, 95% CI 0.88-1.36, p = 0.42, I2 = 76%), or survival beyond 90 days (16% vs. 15%, RR 0.92, 95% CI 0.61-1.40, p = 0.69, I2 = 83%). The TSA showed firm evidence supporting the lack of benefit of IHT in terms of survival at discharge. However, the Z-curves failed to cross the conventional and TSA (futility) boundaries for FNO and survival beyond 90 days, indicating lack of sufficient evidence to draw firm conclusions regarding these outcomes. CONCLUSION: In this meta-analysis of 9 studies, the utilization of IHT was not associated with a survival benefit at discharge. Although the meta-analysis showed lack of benefit of IHT in terms of FNO and survivals beyond 90 days, the corresponding TSA showed high probability of type-II statistical error, and therefore more randomized controlled trials powered for these outcomes are needed.

Short-Term Antiplatelet Versus Anticoagulant Therapy After Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis.

OBJECTIVES: The aim of this study was to compare bleeding, thromboembolic, device-related thrombus (DRT), and all-cause mortality events between patients treated with short-term oral anticoagulation (OAC) and those treated with short-term antiplatelet therapy (APT) following left atrial appendage occlusion (LAAO). BACKGROUND: Short-term OAC is recommended for patients following LAAO. However, in practice many patients receive APT rather than OAC because of excessive bleeding risk. However, the safety and efficacy of APT compared with OAC have been debated. METHODS: A search was conducted of databases for studies comparing OAC with APT following LAAO. The outcomes of interest were all-cause stroke, major bleeding, DRT, and all-cause mortality. Noncomparative studies were pooled into a single study to generate comparisons of the studies' outcomes. Effects measure were pooled using the random-effect model. RESULTS: A total of 83 studies with 12,326 patients (APT, n = 7,900; OAC, n = 4,151) were included. Mean CHA2DS2-VASc and HAS-BLED scores were 4.1 ± 1.6 and 3.0 ± 1.3, respectively. There were no significance differences between the APT and OAC groups with regard to stroke (risk ratio [RR]: 1.04; 95% confidence interval [CI]: 0.54 to 1.98; p = 0.91; I2 = 31%), major bleeding (RR: 1.12; 95% CI: 0.68 to 1.84; p = 0.65; I2 = 53%), DRT (RR: 1.33; 95% CI: 0.74 to 2.39; p = 0.33; I2 = 36%), and all-cause mortality (RR: 1.29; 95% CI: 0.40 to 4.09; p = 0.18; I2 = 36%). These findings persisted in multiple secondary analyses: 1) excluding studies that reported no events; 2) including comparative studies only; 3) excluding patients who were treated with single APT; and 4) removing one study at a time to assess the effect of each study on the overall effect size. There was also no difference in the studies' endpoints among patients who received different LAAO devices. CONCLUSIONS: In a meta-analysis of observational data, there were no differences in the occurrence of stroke, major bleeding DRT, and all-cause mortality in patients treated with short-term OAC or APT following LAAO.

Radial versus femoral access for percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction: Trial sequential analysis.

BACKGROUND: Randomized controlled trials (RCTs) have yielded conflicting results about the impact of transradial access (TRA) versus transfemoral access (TFA) in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: We performed a trial sequential analysis (TSA) of RCTs comparing TRA and TFA in patients with STEMI. The outcomes of interest were 30-day mortality, major bleeding, major adverse cardiovascular events (MACE), myocardial infarction (MI), stroke, and access site complications. RESULTS: A total of 17 studies with 11,992 patients were included in the current TSA. The TRA group had lower 30-day mortality (risk ratio [RR] 0.72, 95% CI 0.58-0.90, P = .003), major bleeding (RR 0.62, 95% CI 0.49-0.79, P = .0001), MACE (RR 0.74, 95% CI 0.58-0.93, P = .01), and access site complications (RR 0.37, 95% CI 0.28-0.48, P < .00001). There was no difference in MI and stroke between the 2groups. Applying TSA boundaries, the z-curve for 30-day mortality, major bleeding, MACE and access site complications crossed the conventional and the TSA boundaries, indicating firm evidence for better outcomes in the TRA group. For MI and stroke, the z-curve failed to cross the conventional and the TSA boundaries for both outcomes, indicating lack of signals of benefit or harm. CONCLUSIONS: In the current TSA, the available data from RCTs support improved 30-day mortality, major bleeding, MACE and access site complication rates in STEMI patients treated by PCI through the radial access.

The dawn of aspirin free strategy after short term dual antiplatelet for percutaneous coronary intervention: meta-analysis of randomized controlled trials.

There is still a debate about the safety and efficacy of an aspirin free strategy after percutaneous coronary intervention (PCI). Hence, we performed a meta-analysis comparing aspirin free strategy to dual antiplatlets therapy (DAPT). Randomized trials (RCTs) comparing aspirin free strategy to DAPT in patients who received PCI were included. The primary outcome of interest was bleeding, defined per the Bleeding Academic Research Consortium (BARC). Secondary outcomes included major adverse cardiovascular and cerebrovascular events (MACE); defined as all-cause mortality, myocardial infarction or stroke, the individual component of MACE and stent thrombosis. A total of 4 RCTs with 29,089 patients were included. There was significant reduction in BARC 2,3 or 5 bleeding events in patients who were treated with aspirin free strategy versus DAPT (HR 0.61, 95% CI 0.39-, p = 0.03, I2 = 89%). Moreover, although there was a trend of reduced major bleeding (BARC 3 or 5) outcomes in the aspirin free strategy group compared to the DAPT group, this did not achieve statistical significance (HR 0.63, 95% CI 0.37-1.06, p = 0.08, I2 = 795). Additionally, there was no difference between the aspirin free strategy and DAPT in term of MACE (HR 0.92, 95% CI 0.82-1.03, p = 0.13, I2 = 0%), all-cause mortality (HR 0.89, 95% CI 0.77-1.04, p = 0.15, I2 = 0%), MI (HR 0.89, 95% CI 0.74-1.08, p = 0.24, I2 = 0%), stroke (HR 1.13, 95% CI 0.65-1.99, p = 0.66, I2 = 60%) or stent thrombosis (HR 0.1.01, 95% CI 0.83-1.22, p = 0.93, I2 = 0%). Aspirin free strategy is as effective as DAPT in reducing MACE with better safety profile in term of bleeding.

Meta-Analysis Comparing Transcatheter Aortic Valve Implantation With Balloon Versus Self-Expandable Valves.

Two transcatheter aortic valve systems are currently in use in the United States; balloon-expandable valves (BEV) and the self-expanding valve (SEV). However, comparative data outcomes between the 2 systems are limited, as only one randomized trial (RCT) performed a head-to-head comparison between BEVs and SEVs. However, there are several RCTs comparing BEV or SEV to surgical valve replacement. In this analysis, we used Bayesian network meta-analysis techniques to compare BEVs and SEVs. The primary outcome was all-cause mortality at maximum follow-up. Secondary outcomes were cardiovascular mortality, stroke, pacemaker implantation, reintervention, heart failure hospitalization, and moderate-severe paravalvular leak (PVL.). Eight RCTs with 8,095 patients were included. With the exception of less pacemaker implantation in BEV versus SEV (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.11 to 0.77, I2 = 51%), there was no difference between BEV and SEV in 30-day outcomes. During long-term follow-up (mean 3 ± 2 years); there was no difference between BEV and SEV in all-cause mortality (hazard ratio [HR] 1.1, 95% CI 0.87 to 1.5, I2 = 19.6%), cardiovascular mortality (HR 1.1, 95% CI 0.73 to 1.6, I2 = 18.5%), stroke (HR 1.3, 95% CI 0.73 to 2.1, I2 = 16.9%), hospitalization (HR 0.87, 95% CI 0.41 to 1.6, I2 = 62%), and reintervention (HR 0.68, 95% CI 0.2 to 2.3, I2 = 62%). New pacemaker implantation and PVL were significantly less in BEV group (HR 0.45, 95% CI 0.24 to 0.80, I2 = 38.2%), and (HR 0.03, 95% CI 0.0004 to 0.28, I2 = 79%), respectively. In conclusion, similar outcomes were seen following transcatheter aortic valve implantation with BEV and SEV with the exception of higher rates of pacemaker implantation and PVL in SEV group.

Ticagrelor after pharmacological thrombolysis in patients with ST-segment elevation myocardial infarctions: insight from a trial sequential analysis.

Few randomized controlled trials (RCTs) have compared ticagrelor to clopidogrel after thrombolytic therapy in patients with ST-segment elevation myocardial infarction (STEMI). To assess the quality of the current evidence, a trial sequential analysis (TSA) of all the available RCTs was performed. A literature search through electronic databases for relevant RCTs was completed. Trial sequential boundaries were applied to the meta-analysis to guard against statistical error, calculate the information size (IS), and assess the quality of the currently available evidence. The safety outcome was bleeding at 30-days and the efficacy outcome was major adverse cardiovascular events at 30-days. There were 3 RCTs with a total of 3999 patients were included. For the safety and efficacy outcomes, there was no difference between the ticagrelor and clopidogrel groups (RR 0.94; 95% CI 0.56-1.60, p = 0.83) and (RR 0.87; 95% CI 0.49-1.52, p = 0.62), respectively. The corresponding TSA revealed an IS of 20,928 and 37,266 for safety and efficacy outcomes, respectively. The Z-curves for both outcomes failed to cross the conventional boundary of significance and TSA boundary, indicating no statistical difference between the ticagrelor and clopidogrel group and lack of firm evidence from the currently available RCTs to draw conclusion. Based on the current available RCTs, there is not enough evidence to support or refute better outcomes with ticagrelor in patients with STEMI treated with thrombolytics. Larger RCTs with enough power are needed before firm recommendations can be applied.

Trial Sequential Analysis Comparing Bleeding and Major Adverse Cardiovascular Events in Patients with Atrial Fibrillation and Acute Coronary Syndrome on Dual versus Triple Therapy.

Objective To assess efficacy and safety of dual therapy (DT) and triple therapy (TT) in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI) and evaluate the quality of evidence with respect to said outcomes based on contemporary randomized trials (RCTs). The efficacy outcome taken was major adverse cardiovascular events (MACE) while safety outcome was major bleeding events. Introduction Appropriate anti-thrombotic therapy is still controversial in patients with AF and concomitant ACS or PCI. We conducted a conventional meta-analysis pooling data from major RCTs to assess the efficacy and safety of DT and TT. Additionally, we utilized advanced analytic properties of trial sequential analysis (TSA) to assess for quality of evidence in this realm. Methods and results A total of 8,732 patients from five major RCTs were enrolled in this study. There was a statistically significant reduction in major bleeding on the DT group compared to the TT group (RR 0.65, 95% CI 0.48, 0.86). The incidence of major adverse cardiovascular events (MACE) was similar in both groups (RR 0.97, 95% CI 0.8,1.17). The trial sequential analysis showed strong evidence supporting reduction in bleeding from current major RCTs while being inconclusive based on MACE outcome. Conclusion Sufficient quality evidence could be ascertained from contemporary RCTs on reduced incidence of bleeding in DT patients compared to TT patients. Further adequately powered RCTs are needed to ensure non-inferiority of DT over TT with respect to MACE outcome.

Meta-Analysis of Outcomes of Transcatheter Aortic Valve Implantation Among Patients With Low Gradient Severe Aortic Stenosis.

Transcatheter aortic valve implantation (TAVI) has emerged as an effective therapy for patients with severe aortic stenosis (AS). However, data on TAVI outcomes in patients with low gradient (LG) AS are limited. We performed a meta-analysis of studies comparing TAVI outcomes between patients with classic high gradient (HG) and LG AS through November 2018. The 30-day mortality, mid-term all-cause, and cardiovascular mortality at maximum follow-up were compared between patients with HG and LG AS (Pairwise meta-analysis), and between the three distinct groups of AS including HG, paradoxical low-flow low-gradient and low gradient with reduced ejection fraction (rEF-LG) (Network meta-analysis). Nineteen studies (n = 27,204 patients) met the inclusion criteria. The HG group had less 30-day, mid-term all-cause and cardiovascular mortality compared with the low-gradient AS group overall, (6% vs 7.5%, OR 0.76, 95% CI 0.66 to 0.87, I2 = 18%), (21% vs 29%, OR 0.59, 95% CI 0.52 to 0.67, I2 = 62%), and (12.6% vs 18.7%, OR 0.61, 95% CI 0.49 to 0.76, I2 = 62%), respectively, p <0.0001. These outcomes were confirmed in a trial sequential analysis in which the cumulative Z-curve crossed the conventional test boundary as well as the trial sequential monitoring boundary for all outcomes. The network meta-analysis revealed that patients with rEF-LG had similar outcomes to those with pLFLG, and both had worse outcomes than patients with classic HG AS. In conclusion patients with classic HG have better 30-day mortality, mid-term all-cause and cardiovascular mortality compared with LG patients following TAVI. Among patients with LG severe AS, TAVI outcomes were similar in patients with rEF-LG and pLFLG.

De-Escalation of Antiplatelet Therapy in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Clinical Trials.

AIMS: Patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI) are recommended to be placed on potent P2Y12 blockade. However, the long-term bleeding risk is high. Therefore, despite no definitive evidence, switching to clopidogrel beyond the acute phase is common. We aimed to evaluate the clinical outcomes of antiplatelet de-escalation compared with continuation in patients treated with PCI. METHODS: We searched databases for randomized clinical trials (RCTs) that evaluated the safety and efficacy of antiplatelet de-escalation compared with continuation in patients treated with PCI. Pooled summary estimates were calculated. RESULTS: We included 3 RCTs with 3391 patients (median follow-up: 12 months). Compared with the continued group, the net clinical outcome (composite of bleeding or thrombotic events) was significantly reduced in the group switched to clopidogrel (8.7% vs 12.1%; risk ratio [RR]: 0.64; 95% confidence interval [CI]: 0.43-0.97; P = .03). However, there were similar clinical outcomes between groups for major adverse cardiovascular events (MACE; RR: 0.78; 95% CI: 0.55-1.11; P = .17), all Bleeding Academic Research Consortium (BARC) types bleeding (RR: 0.61; 95% CI: 0.33-1.11; P = .10), or BARC types ≥2 bleeding (RR: 0.49; 95% CI: 0.19-1.26; P = .14). CONCLUSIONS: Our results suggest a net clinical benefit of de-escalation therapy shortly after PCI, without increased risk of MACE. Larger randomized trials will be necessary to confirm these findings.

Alcohol septal ablation vs myectomy for symptomatic hypertrophic obstructive cardiomyopathy: Systematic review and meta-analysis.

BACKGROUND: Surgical myectomy (SM) and Alcohol septal ablation (ASA) are effective therapies for patients with hypertrophic cardiomyopathy who remain symptomatic despite medical therapy. A plethora of data has recently emerged on the long-term outcomes of these procedures. We hence sought to perform an updated meta-analysis comparing both procedures. METHODS: Studies reporting long-term (>3-years) outcomes of SM and/or ASA were included. The primary endpoint was all-cause mortality. Secondary endpoints included cardiovascular mortality, sudden cardiac death (SCD), reintervention, and complications including death, pacemaker implantation, and stroke. RESULTS: Twenty-two ASA cohorts (n = 4213; follow-up = 6.6-years) and 23 SM cohorts (n = 4240; follow-up = 6.8-years) were included. Septal myectomy was associated with higher periprocedural mortality and stroke (2% vs 1.2%, P = 0.009 and 1.5% vs 0.8% P = 0.013, respectively), but ASA was associated with more need of pacemaker (10% vs 5%, P < 0.001). During long-term follow-up, all-cause mortality, cardiovascular mortality, and sudden cardiac death rates were 1.5%, 0.4%, and 0.3% per person-year in the ASA group and 1.1%, 0.5%, and 0.3% per person-year in the SM group (P = 0.21, P = 0.53, P = 0.43), respectively. Repeat septal reduction intervention(s) were more common after ASA (11% vs 1.5%, P < 0.001). CONCLUSION: Compared with SM, ASA is associated with lower periprocedural mortality and stroke but higher rates of pacemaker implantations and reintervention. However, there was no difference between ASA and SM with regards to long-term all-cause mortality, cardiovascular mortality, or SCD.

CYP2C19 pharmacogenetics versus standard of care dosing for selecting antiplatelet therapy in patients with coronary artery disease: A meta-analysis of randomized clinical trials.

OBJECTIVES: This study aimed to evaluate the efficacy and safety of personalized genotype-guided selection of antiplatelet therapy versus standard of care in patients undergoing percutaneous coronary intervention (PCI). BACKGROUND: Clopidogrel is the most frequently used P2Y12 receptor antagonist in patients with coronary artery disease. However, genetic variations of clopidogrel are associated with inter-individual response variability which could limit its efficacy. METHODS: Electronic databases were searched for all randomized clinical trials (RCTs) evaluating genotype-guided therapy versus standard of care in patients undergoing stent implantation. Aggregated risk ratios (RRs) and 95% CIs were calculated using a random-effects model. RESULTS: We included 6 RCTs with a total of 2,371 patients. When compared with standard of care, the use of genotype-guided therapy did not significantly reduce major adverse cardiovascular events (MACE) (RR 0.67; 95% CI: 0.35-1.27; P = 0.22). However, MACE was significantly reduced in the subset of trials which enrolled only acute coronary syndromes (ACS) (P < 0.01). In addition, there was a significant reduction in myocardial infarction in the genotype-guided group (RR 0.44; 95% CI: 0.28-0.70; P < 0.01; I2 = 0%). Other clinical outcomes were not significantly different: cardiovascular mortality (RR 0.68; 95% CI: 0.27-1.74; P = 0.42), stroke (RR 0.62; 95% CI: 0.23-1.65; P = 0.34), stent thrombosis (RR 0.37; 95% CI: 0.13-1.06; P = 0.06), and bleeding (RR 0.68; 95% CI: 0.43-1.06; P = 0.09). CONCLUSION: In patients undergoing stent implantation, MACE with genotype-guided therapy was not significantly reduced; however, there was a signal towards reduction of MACE in ACS patients, as well as a lower rate of MI, though this will require further confirmation in adequately powered trials.

Association between changes in the intrathoracic impedance and ventricular arrhythmias in patients with heart failure.

BACKGROUND: Ventricular arrhythmias (VAs) are independently related to mortality risk in patients with heart failure (HF). The wide availability of implantable cardioverter defibrillators and cardiac resynchronization therapy devices now offers an opportunity to clinically correlate the two disease processes. We hypothesized that there is an association between changes in the intrathoracic impedance and episodes of VA. METHODS: Nonconcurrent prospective study of adults (age >20 years) with known HF with reduced ejection fraction (<35%). The OptiVol threshold was categorized as follows: 0-30 Ω-days, 31-60 Ω-days, 61-90 Ω-days, 91-120 Ω-days, and >120 Ω-days. Patients with OptiVol values at 0-30 Ω-days were used as the reference group. Receiver operating characteristic analysis was used to estimate the sensitivity and specificity at each threshold. RESULTS: Of the 87 eligible patients, 65.5% were males. The mean age of the sample was 73.3 years (±12.7). Compared to patients in the 0-30 Ω-days category, those in the 31-60, 61-90, 91-120, and >120 Ω-days groups had, on average, 1.48, 1.64, 2.24, and 1.6 more VAs, respectively (P = 0.002, 0.009, 0.010 and 0.009, respectively). The sensitivity and specificity of each threshold were as follows: 82.6% and 61.7% at 31-60 Ω-days, 43.5% and 78.3% at 61-90 Ω-days, 30.4% and 85.0% at 91-120 Ω-days, and 21.7% and 88.3% at >121 Ω-days. CONCLUSION: Our study found a significant positive relationship between changes in intrathoracic impedance and episodes of VAs in patients with HF.

Meta-Analysis of Carvedilol for the Prevention of Anthracycline-Induced Cardiotoxicity.

Anthracycline is a commonly prescribed antineoplastic agent. As a consequence of the growing number of cancer survivors, the incidence of anthracycline-induced cardiotoxicity is increasing. However, the optimal primary preventive strategy is lacking. Therefore, we conducted a meta-analysis of all randomized controlled trials to evaluate the efficacy of carvedilol for the primary prevention of anthracycline-induced cardiotoxicity. A comprehensive search of electronic databases was conducted. The primary and secondary outcomes were the occurrence of low left ventricular ejection fraction, and the absolute change in left ventricular ejection fraction (LVEF), respectively. We calculated the odds ratios for the primary outcome and the weighted mean differences for the secondary outcomes using a random-effects model. We included 8 randomized controlled trials (633 total patients). Our results showed significantly reduced rates of low LVEF favoring the carvedilol group (3.2% vs 5.8%; odds ratios: 0.42; 95% confidence interval: 0.18 to 0.99; p = 0.05). Furthermore, there were significantly smaller reductions in LVEF in carvedilol-treated patients than in placebo-treated patients (mean differences: 2.41%; 95% confidence interval: 0.01 to 4.81; p = 0.05). In conclusion, prophylactic administration of carvedilol in anthracycline-treated cancer patients may reduce the early onset of left ventricular dysfunction compared with placebo.

Intra-thoracic Impedance and the Onset of Atrial and Ventricular Tachyarrhythmias: A Meta-analysis.

BACKGROUND AND PURPOSE: Advances of implantable cardioverter-defibrillator (ICD) devices allow correlating changes in the intra-thoracic impedance (TI), an indicator of fluid overload, with the onset of arrhythmic events. In an attempt to attain a better understanding of this relationship, we conducted a meta-analysis of studies that investigated the association between TI changes and the onset of AT/AF and/or VT/VF in patients with ICD devices. METHODS: We performed a meta-analysis of studies published through January 2017 that reported an association between a decrease in the TI measured by the OptiVol fluid index (OI) and occurrence of AT/AF and VT/VF. We searched four databases: PubMed, Embase, CINAHL and Cochrane. Effect estimates were extracted from each study in the form of odds ratio (OR) and 95% confidence intervals. RESULTS: We identified 8 articles with results of the original research, allowing us to extract data for the OR calculation. Our pooled sample included 94,666 patients from 4 studies for AT/AF and 23,601 patients from 6 studies for VT/VF. Two studies were included in both analyses. The pooled OR for fluid index threshold crossing of 60Ω-days was 1.56 (95% CI 1.35, 1.81) for VT/VF and 1.8 (95% CI 1.43, 2.27) for AT/AF. CONCLUSION: The findings of our meta-analysis based on the large pooled population of >110,000 patients, reveal that decreased TI (measured by OI threshold crossing of 60Ω-days) is a significant risk factor for the onset of AT/AF and VT/VF.

Oral Cancer Awareness Among Dental Patients in Omdurman, Sudan: a cross-sectional Study.

BACKGROUND: Oral cancer is a preventable disease. Its occurrence is mostly due to lifestyle. In Sudan, the use of smokeless tobacco (Toombak) has long been linked to oral cancer. Knowledge of the signs and symptoms of oral cancer may well aid in early diagnosis and treatment. This is bound to result in increasing survival rates, as well as reducing the oral cancer burden on the society. This study aimed to assess oral cancer awareness regarding knowledge of signs, symptoms, risk factors and sources of the information. Furthermore, it attempts to evaluate attitudes towards oral cancer screening and any previous experience of screening, amongst dental patients attending University of Science and Technology (UST) Dental Teaching Hospital. Omdurman, Sudan. METHODS: A hospital based cross-sectional study, interviewer-administered questionnaire was conducted amongst 500 adult patients attending the UST Dental Hospital during 2015. RESULTS: A total of 57.7% (286) of the individuals demonstrated good knowledge of signs and symptoms, whereas 49% (139) expressed good knowledge of risk factors of oral cancer. For the majority of the individuals 66.1% (290), the most common source of information about oral cancer was from the media, while 33.9% individuals (149), obtained knowledge from direct contact of health workers. The overwhelming majority, 93.2% (466) never screened for oral cancer despite their positive attitude towards it 66.4% (332). Knowledge of risk factors associated significantly with those reported positive attitude towards oral cancer screening and those reported direct contact with health workers as a source of information, (p ≤ 0.001). Moreover, females and those living in urban districts scores higher than their counterpart in knowledge of risk factor of oral cancer. In addition, those employed 58.6% (280) and 62.8% (164) with correct believes about oral cancer showed significant association with positive knowledge of signs and symptoms (p ≤ 0.05). CONCLUSIONS: Awareness levels, knowledge of risk factors and identifying early signs and symptoms of oral cancer necessitate the need for more structured preventive programs using media. Dentists and health workers should do more because they have a pivotal role in early diagnosis by performing oral cancer screening, raising levels of knowledge and in rectifying misconceptions about oral cancer. This would entail a reduction in high rates of morbidity and mortality associated with oral cancer.