Meta-analysis of optimal timing of coronary intervention in non-ST-elevation acute coronary syndrome.

OBJECTIVES: We conducted a meta-analysis of randomized controlled trials (RCTs) to compare the efficacy and safety of early versus delayed invasive management of non-ST-elevation acute coronary syndrome (NSTE-ACS). BACKGROUND: Coronary angiography is recommended for patients with NSTE-ACS, however, the optimal timing for this remains controversial. METHODS: Literature search of Pubmed/MEDLINE, Cochrane Library, and Embase for all RCTs that compared early with delayed invasive approaches in treating NSTE-ACS was conducted by two independent authors. Primary outcome was major adverse cardiovascular events (MACE), while the secondary outcomes included cardiovascular mortality, all-cause mortality, myocardial infarction (MI), and bleeding events. The Mantel-Haenszel random-effects model was used to calculate risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS: We included 14 RCTs (9,637 patients, mean age 65.4, 67% males). The early invasive strategy was associated with a lower incidence of MACE compared with the delayed invasive strategy (RR 0.65, 95%CI 0.49-0.87; p = .003). Subgroup analysis according to GRACE score showed a lower incidence of MACE with early invasive strategies in GRACE >140 patients (p for interaction = .002). Furthermore, recurrent ischemia was lower in patients with an early invasive strategy (RR 0.42, 95%CI 0.26-0.69; p < .0005). In contrast, there were no significant differences in all-cause mortality, cardiovascular mortality, MI, or bleeding events between groups (all p > .05). CONCLUSIONS: Among patients with NSTE-ACS, an early invasive strategy was associated with lower incidence of MACE and recurrent ischemia compared with delayed invasive strategy. There were no significant differences in all-cause mortality, cardiovascular mortality, MI, or bleeding events between groups.

Targeted Temperature Management in Cardiac Arrest Patients With an Initial Non-Shockable Rhythm: A Systematic Review and Meta-Analysis.

BACKGROUND: Targeted temperature management (TTM) is now recommended for patients presenting with an out-of-hospital cardiac arrest. However, there are limited data that support its use in patients with an initial non-shockable rhythm (NSR). METHODS: A literature search of PubMed/MEDLINE, Cochrane Library, and Embase was conducted by two independent authors for studies that compared TTM along with standard care versus standard care alone in treating cardiac arrest with initial NSR. Outcomes were short-term and long-term survival, and a Cerebral Performance Category (CPC) score of 1 to 2 at the longest follow-up period. The Mantel-Haenszel random-effects model was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Trial sequential analysis (TSA) was performed on the randomized controlled trials (RCTs). RESULTS: Thirty studies were included in the final analysis: 25 observational and five RCTs, totalling 10,703 patients, 4,023 of whom received TTM and 6,680 received standard care alone. Compared with standard care, patients who presented with an initial NSR cardiac arrest and received TTM (target of 32°C -34°C) had a significantly higher short-term survival (OR 1.44 95% CI 1.15-1.81; P = 0.002), long-term survival (OR 1.52 95% CI 1.03-2.26; P = 0.04), and CPC score of 1 to 2 (OR 1.63 95% CI 1.22-2.17; P = 0.0010). Sensitivity analyses by including only RCTs showed a trend, although not significant, toward better short-term survival (OR 1.25 95% CI 0.82-1.89; P = 0.30), long-term survival (OR 1.15 95% CI 0.80-1.66; P = 0.46), and neurologic outcomes (OR 1.51 95% CI 0.81-2.80; P = 0.19). However, TSA performed on the RCTs revealed that the results were inconclusive. CONCLUSION: Among patients who survived cardiac arrest with an initial NSR, TTM is associated with a higher rate of survival and favorable neurological outcomes compared with no TTM. However, analyses from the included RCTs did not support this conclusion.

Optimal timing of coronary intervention in patients resuscitated from cardiac arrest without ST-segment elevation myocardial infarction (NSTEMI): A systematic review and meta-analysis.

OBJECTIVE: Performing immediate coronary angiography (CAG) in patients with a cardiac arrest and a non-ST-elevation myocardial infarction (NSTEMI) remains a highly debated topic. We performed a meta-analysis aiming to evaluate the influence of immediate, delayed, and no CAG in patients with cardiac arrest and NSTEMI. METHODS: A comprehensive literature review of Pubmed/MEDLINE, Cochrane Library, and Embase was performed for all studies that compared immediate CAG to delayed or no CAG in the setting of cardiac arrest and NSTEMI. The primary outcome was long-term mortality and secondary outcomes included short-term mortality and a Cerebral Performance Category (CPC) score of 1-2 at the longest follow-up period. A random-effects model was used to report odds ratios (ORs) with Bayesian 95% credible intervals (CrIs), and ORs with 95% confidence intervals (CIs) for both network and direct meta-analyses, respectively. RESULTS: 11 studies were included in the final analysis: 8 observational, 1 post-hoc analysis and 2 randomized trials, totaling 3702 patients. The mean age was 63.8±12.8 years with 78% males. We found that immediate and delayed CAG were associated with lower long-term mortality when compared to no CAG (OR 0.21; 95% CrI 0.05-0.82) and (OR 0.11; 95% CrI 0.03-0.43), as well as lower short-term mortality (OR 0.17; 95% CrI 0.04-0.64) and (OR 0.07; 95% CrI 0.01-0.29), respectively. In addition, immediate and delayed CAG were associated with a significantly higher number of patients with a CPC score of 1-2 (OR 4.15; 95% CrI 1.10-16.10) and (OR 4.67; 95% CrI 1.53-15.12), respectively. There were no significant differences between immediate or delayed CAG regarding long-term mortality, short-term mortality, or favorable CPC score. CONCLUSIONS: Among patients who survived cardiac arrest with an NSTEMI, CAG is associated with a higher rate of survival and favorable neurological outcomes compared with no CAG. There were no differences between immediate and delayed strategies.

Best duration of dual antiplatelet therapy after drug-eluting stent implantation: an updated network meta-analysis of randomized controlled trials.

Background: Drug-eluting stent(DES) implantation is the main interventional treatment for coronary artery disease, and dual antiplatelet therapy(DAPT) remains the gold standard strategy to prevent ischemic events. However, the optimal duration of DAPT after DES implantation remains controversial. Therefore, we aimed to evaluate the best duration of DAPT following DES implantation. Method: We searched PubMed, Embase, Cochrane Library, and clinicaltrials.gov for all randomized clinical trials(RCTs) that compared different durations of DAPT after DES implantation. Major adverse cardiac events(MACE) and major bleeding were the primary and secondary outcomes, respectively. Results: We included 16 RCTs (n = 42,993). The mean age of included patients was 63.1 ± 10.1. The primary outcome was statistically significant for lower MACE in patients who received DAPT for 24-48 months (mo) following DES when compared with those who received 3-6 mo of DAPT (odds ratio [OR] 0.75; 95% credible interval [CI] 0.58-0.97). There was nonstatistically significant difference in MACE when comparing those who received 12 mo of DAPT to those taking either 3-6 mo of DAPT (OR 0.86; 95% CI 0.69-1.08) or 24-48 mo of DAPT (OR 0.87; 95% CI 0.72-1.05). In contrast, major bleeding was significantly lower in those who received 3-6 mo of DAPT (OR 0.32; 95% CI 0.17-0.54) and 12 mo of DAPT (OR 0.43; 95% CI 0.27-0.63) than in those who received 24-48 mo of DAPT. Conclusion: In patients who undergo DES implantation, a longer duration of DAPT is associated with lower MACE, despite the increased risk of major bleeding events. Therefore, individualizing the duration of DAPT after DES according to the patient's risk of bleeding and recurrent ischemia is recommended.

Transcatheter versus surgical aortic valve replacement in low-risk surgical patients: A meta-analysis of randomized clinical trials.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is a valid option for patients with high or intermediate surgical risk. However, clinical outcomes of TAVR in low-risk patients are lacking. Our aim was to evaluate the efficacy and safety of TAVR versus surgical aortic valve replacement (SAVR) in low-surgical-risk patients. METHODS: Electronic database review was conducted for all randomized clinical trials (RCTs) that compared TAVR versus SAVR in low-risk patients. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model. RESULTS: We included 3 RCTs totaling 604 patients (310 TAVR and 294 SAVR). Our results showed no significant difference in mortality between TAVR compared with SAVR (RR = 0.71; 95% CI = 0.22-2.30; P = 0.56), however, there was a significantly increased risk of pacemaker implantation (RR = 7.28; 95% CI = 3.94-13.42; P < 0.01) and moderate/severe paravalvular leakage (PVL) (RR = 6.74; 95% CI = 1.31-34.65; P = 0.02) with TAVR. Nevertheless, TAVR demonstrated a significantly reduced risk of post-procedural bleeding (RR = 0.40; 95% CI = 0.30-0.54; P < 0.01) and new-onset atrial fibrillation (RR = 0.36; 95% CI = 0.27-0.47; P < 0.01). Other clinical outcomes were not significantly different between the groups and included cardiovascular mortality, stroke, transient ischemic attack, and myocardial infarction. CONCLUSIONS: Among low-risk patients, TAVR offered comparable efficacy outcomes and fewer bleeding events compared with SAVR. There were increased risks of pacemaker implantation and PVL associated with TAVR, though lower atrial fibrillation risks.