Warfarin vs non-vitamin K oral anticoagulants for left atrial appendage thrombus: A meta-analysis.

INTRODUCTION: Novel oral anticoagulants (NOACs) are commonly used for thromboembolic risk reduction and treatment of pulmonary embolism and deep venous thrombosis. However, data regarding their efficacy and safety in comparison to warfarin for left atrial appendage thrombus is limited. METHODS: A comprehensive literature search in PubMed, Google Scholar, and Cochrane Review from inception to 30 October 2019 was performed. Studies reporting clinical outcomes comparing warfarin vs NOACs were included. Two investigators independently extracted the data and individual quality assessment was performed. A meta-analysis was performed using random-effects model to calculate risk ratio (RR) and 95% confidence interval (CI). The analysis was performed using RevMan 5.3. RESULTS: Four studies met inclusion criteria and a total of 322 patients were included of whom 141 were in the NOAC arm and 181 were in the warfarin arm. There was no significant difference in thrombus resolution between the two groups (RR, 1.00; 95% CI [0.77-1.29; P = .98]). There was no significant difference in major bleeding (RR, 1.30; 95% CI [0.14-12.21; P = .82]) or stroke (RR, 0.42; 95% CI [0.09-2.06; P = .29]) between the two groups. CONCLUSION: The results of our meta-analysis show that NOACs are as efficacious and safe as warfarin in the treatment of left atrial appendage thrombus in patients with non-valvular atrial fibrillation.

Comparison of nationwide trends in 30-day readmission rates after carotid artery stenting and carotid endarterectomy.

OBJECTIVE: Carotid revascularization procedures, carotid artery stenting (CAS) and carotid endarterectomy (CEA), are among the most common vascular interventions performed in the United States, with significant resource utilization. Whereas multiple studies have reported outcomes after these procedures, data regarding 30-day readmission rates after these interventions remain scant. METHODS: The U.S. Nationwide Readmission Database (2010-2014) was queried to identify all patients ≥18 years who were readmitted within 30 days after a hospital discharge for CEA or CAS. RESULTS: Among 476,260 patients included, 13.5% underwent CAS and 86.5% underwent CEA. The combined 30-day readmission rate for all carotid revascularization procedures was 9.2% (10.6% after CAS and 9.0% after CEA). After 1:3 propensity matching, CAS was associated with higher risk of readmission compared with CEA (10.4% vs 9.4%). Neurologic complications and cardiac conditions were the two most common causes of readmission after both CAS (29.7% and 23.7%, respectively) and CEA (28.2% and 21.7%, respectively). The 30-day readmission rates were higher in CAS patients across all age groups as well as in those with a low or high baseline burden of comorbidities. CONCLUSIONS: In this large nationwide study, CAS was associated with higher 30-day readmission rates compared with CEA irrespective of age or baseline burden of comorbidities. Neurologic or cardiac adverse events were responsible for >50% of readmissions after CAS and CEA.

Renal sympathetic denervation improves clinical outcomes in patients undergoing catheter ablation for atrial fibrillation and history of hypertension: A meta-analysis.

BACKGROUND: Currently, there is limited data regarding the impact of adjunctive renal sympathetic denervation (RSDN) with pulmonary vein isolation (PVI) in hypertensive patients with atrial fibrillation (AF). METHODS: A comprehensive literature search for studies comparing RSDN + PVI vs PVI alone for AF and history of hypertension until 1 January 2019 was performed. The results were expressed as risk ratio (RR) for the categorical variables and mean difference (MD) for the continuous variables with 95% confidence intervals (CIs). RESULTS: A total of six eligible (four randomized and two prospective nonrandomized) studies consisting of 432 patients (306 paroxysmal AF and 126 persistent AF) were included (RSDN + PVI group: 186 patients and PVI group: 246 patients). Follow-up is more than or equal to 1 year. Compared with PVI, RSDN + PVI significantly decreased the risk of AF recurrence (RR = 0.58, 95% confidence interval [CI] = 0.47-0.72, P < 0.00001) on follow-up. Fluoroscopy (MD = +5.53 minutes, 95% CI = 0.76-10.31, P = 0.02) and procedure time (MD = +34.85 minutes, 95% CI = 23.55-46.16, P < 0.00001) was significantly longer with the PVI + RSDN group compared with PVI alone. There were no significant differences in complications between both groups. Test of heterogeneity was low for all clinical outcomes (I2 = 0%). CONCLUSION: Our meta-analysis demonstrates that RSDN as an adjunct to PVI appears to be safe and improves clinical outcomes in both paroxysmal and persistent AF and history of hypertension.

Efficacy and safety of single vs dual antiplatelet therapy in patients on anticoagulation undergoing percutaneous coronary intervention: A systematic review and meta-analysis.

BACKGROUND: Selection of an appropriate antithrombotic regimen in patients requiring oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) still remains a challenge. An ideal 9-2regimen should balance the risk of bleeding against ischemic benefit. METHODS: A comprehensive literature search for studies comparing triple antithrombotic therapy (TAT) vs double antithrombotic therapy (DAT) in patients requiring OAC undergoing PCI was performed in clinicalTrials.gov, PubMed, Web of Science, EBSCO Services, Cochrane Central Register of Controlled Trials, Google Scholar, and various scientific conference sessions from inception to May 1st, 2019. A meta-analysis was performed using random-effects model to calculate risk ratio (RR) and 95% confidence interval (CI). RESULTS: Fifteen studies were eligible and included 13 967 patients, of which 7349 received TAT and 6618 received DAT. Compared with DAT, TAT was associated with lower risk of myocardial infarction (RR, 0.82; 95%CI, 0.69-0.98; P = .03) and stent thrombosis (RR, 0.66; 95%CI, 0.46-0.96; P = .03). There was no difference in risk of trial defined major adverse cardiac events, all-cause mortality, and stroke between two groups. Compared with DAT, TAT was associated with higher risk of trial defined major bleeding (RR, 1.67; 95%CI, 1.38-2.01; P < .00001), including thrombolysis in myocardial infarction major bleeding (RR, 1.81; 95%CI, 1.47-2.24; P < .00001) but no significant difference in risk of intracranial bleeding. CONCLUSION: In patients requiring OAC undergoing PCI, TAT was associated with a lower risk of myocardial infarction but with a significantly higher risk of major bleeding when compared with DAT.

Etiologies, trends, and predictors of readmission in ST-elevation myocardial infarction patients undergoing multivessel percutaneous coronary intervention.

BACKGROUND: Recent trials have shown benefits with percutaneous coronary intervention (PCI) on nonculprit coronary vessels in select ST-elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (CAD). However, readmission rates and causes in this high-risk group are unknown. Objective of this study is to explore pattern, causes and factors associated with 30-day readmission after multivessel PCI in STEMI patients. METHODS AND RESULTS: Nationwide Readmissions Data (NRD) between 2010 and 2014 was utilized to identify multivessel PCI cases in STEMI patients using appropriate ICD-9 codes. We evaluated 30-day readmission rate and factors associated with 30-day readmission. Hierarchical logistic regression model was used to identify factors associated with 30-day readmission. Among 22,257 STEMI patients who survived to discharge after multivessel PCI, 2,302 (10.3%) were readmitted within 30-days. Subsequent unresolved/aggravated cardiac issues most commonly triggered readmission (62.66%). Among cardiac causes, heart failure and ischemic heart disease were most frequent etiologies. Advancing age (OR: 1.073, 95%CI: 1.026 to 1.122, p = .002), female sex (OR: 1.36, 95%CI: 1.23 to 1.50, p < .001), comorbid conditions like chronic kidney disease (CKD; OR: 1.35, 95%CI: 1.17 to 1.57, p = .001), congestive heart failure (CHF; OR: 1.40, 95%CI: 1.24 to 1.57, p = .04), anemia (OR: 1.16, 95%CI: 1.002 to 1.34, p = .04), and utilization of a mechanical circulatory support (MCS) device (OR: 1.45, 95%CI: 1.19 to 1.77, p < .001) during the index procedure were predictive of subsequent readmission within 30 days. CONCLUSION: In this large nationally representative study, nearly one in 10 patients were readmitted within 30 days from discharge after index admission for multivessel PCI in STEMI, most commonly for cardiac causes.

Frequency of 30-day readmission and its causes after percutaneous coronary intervention in acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: Survival after percutaneous coronary intervention (PCI) in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) has increased over the years. Short-term readmission rates in this high-risk population remain unknown. METHODS: We queried the United States (U.S.) Nationwide Readmission Database (NRD) from January 2010 to November 2014 using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9 CM) codes to identify all patients ≥18 years readmitted within 30 days after surviving an index hospitalization for PCI in AMI-CS. Incidence, etiologies, and predictors of 30-day readmission were analyzed. RESULTS: Among 46,435 patients who survived to discharge after PCI in AMI-CS, 9,020 (19.4%) were readmitted within 30 days. Median time to 30-day readmission was 11 days. Cardiac conditions were the most common causes of readmission (57.8%). Heart failure was the leading readmission diagnosis (24.8%). Private insurance including HMO and self-pay were predictive of lower 30-day readmission. Among other covariates, female sex, comorbidities such as heart failure, atrial fibrillation, in-hospital complications such as major bleeding, sepsis, respiratory complications, AKI requiring dialysis, utilization of mechanical circulatory support (IABP and ECMO) were independently predictive of 30-day readmission. Trend analysis showed decline in 30-day readmission rates from 21.9% in 2010 to 17.9% in 2014 (ptrend < 0.001). CONCLUSION: In this large real-world database, one in five patients receiving PCI in AMI-CS was readmitted within 30 days after discharge. Cardiac conditions were the most common causes of readmission. Insurance type had significant influence on 30-day readmission.

Temporal trends of survival and utilization of mechanical circulatory support devices in patients with in-hospital cardiac arrest secondary to ventricular tachycardia/ventricular fibrillation.

BACKGROUND: Pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) is the initial rhythm in a third of in-hospital cardiac arrest patients. Mechanical circulatory support (MCS) device use remains poorly understood in this population. METHODS: We conducted an observational analysis of temporal trends in the utilization of MCS in VT/VF IHCA between January 2008 and December 2014 utilizing the Nationwide Inpatient Sample (NIS) database. Using multivariable analysis, we assessed factors associated with MCS use and survival to discharge. RESULTS: Among 151,628 hospitalizations with VT/VF IHCA, 14,981 (9.9%) received MCS. Intra-aortic balloon pump (IABP) was the most commonly used MCS (9.1%). From 2008 to 2014, there was significant increase in the utilization of MCS (8.7-11%; ptrend < 0.0001). On multivariable analysis, there was 12-fold increase and three-fold increase in the utilization of PVAD and ECMO respectively; however, there was no significant change in the use of IABP. Over the seven-year sample period, there was significant increase in the overall survival to hospital discharge (35.4-43.5%; ptrend < 0.0001). Survival to hospital discharge increased in both MCS and non-MCS groups. CONCLUSION: There was significant increase in utilization of MCS after VT/VF IHCA during the study period. IABP was the most commonly utilized MCS. The survival to hospital discharge increased in the overall study population including both MCS and non-MCS groups. Future studies are needed to identify patient population most likely to benefit from the use of MCS after VT/VF IHCA.

Overutilisation of imaging studies for diagnosis of pulmonary embolism: are we following the guidelines?

OBJECTIVE: To evaluate if imaging studies such as CT pulmonary angiography (CTPA) or ventilation-perfusion (V/Q) scan are ordered according to the current guidelines for the diagnosis of pulmonary embolism (PE). METHODS: We performed a retrospective observational cohort study in all adult patients who presented to the Sparrow Hospital Emergency Department from January 2014 to December 2016 and underwent CTPA or V/Q scan. We calculated the Wells' score retrospectively, and d-dimer values were used to determine if the imaging study was justified. RESULTS: A total of 8449 patients underwent CTPA (93%) or V/Q scan (7%), among which 142 (1.7%) patients were diagnosed with PE. The Wells' criteria showed low probabilities for PE in 96 % and intermediate or high probabilities in 4 % of total patients. Modified Wells' criteria demonstrated PE unlikely in 99.6 % and PE likely in 0.4 % of total patients. D-dimer was obtained in only 37 % of patients who were unlikely to have a PE or had a low score on Wells' criteria. Despite a low or unlikely Wells' criteria score and normal d-dimer levels, 260 patients underwent imaging studies, and none were diagnosed with PE. CONCLUSION: More than 99 % of CTPA or V/Q scans were negative in our study. This suggests extraordinary overutilisation of the imaging methods. D-dimer, recommended in patients with low to moderate risk, was ordered in only one-third of patients. Much greater emphasis of current guidelines is needed to avoid inappropriate utilisation of resources without missing diagnosis of PE.

Propensity matched comparison of in-hospital outcomes of TAVR vs. SAVR in patients with previous history of CABG: Insights from the Nationwide inpatient sample.

BACKGROUND: The incidence of patients with previous history of coronary artery bypass grafting (CABG) presenting for aortic valvular replacement has been consistently on the rise. Repeat sternotomy for surgical aortic valve replacement (SAVR) carries an inherent risk of morbidity and mortality when compared to Transcatheter aortic valve replacement (TAVR). METHODS: The Nationwide inpatient sample (NIS) from 2012 to 2014 was queried using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9-CM) codes to identify all patients ≥ 18 years with prior CABG who underwent TAVR (35.05 and 35.06) or SAVR (35.21 and 35.22). Propensity score matching (1:1) was performed and in-hospital outcomes were compared between matched cohorts. RESULTS: From 2012 to 2014, there was progressive increase in the annual number of TAVR procedures from 1485 to 4020, with a decrease in patients undergoing SAVR from 2330 to 1955 (Ptrend < 0.0001) in the above population. There was no significant difference in in-hospital mortality rates. Compared to SAVR, TAVR was associated with lower risk of stroke (1.2% vs. 3.3%, P = 0.009), AKI (12.9% vs. 21.3%, P < 0.0001), myocardial infarction (0.9% vs. 2.7%, P = 0.01) and major bleeding (9.1% vs. 25.1%, P < 0.0001). TAVR was associated with higher risk of pacemaker implants (9.6% vs. 4.9%, P = 0.001) and trend toward lower risk of vascular complications (2.3% vs. 4.1%, P = 0.05). CONCLUSION: In this large cohort of patients with previous CABG, there is no significant difference in in-hospital mortality between TAVR and SAVR. TAVR was associated with lower risk of in-hospital outcomes.

Valve in valve transcatheter aortic valve implantation (ViV-TAVI) versus redo-Surgical aortic valve replacement (redo-SAVR): A systematic review and meta-analysis.

BACKGROUND: Bioprosthetic (BP) valves have been increasingly used for aortic valve replacement over the last decade. Due to their limited durability, patients presenting with failed BP valves are rising. Valve in Valve - Transcatheter Aortic Valve Implantation (ViV-TAVI) emerged as an alternative to the gold standard redo-Surgical Aortic Valve Replacement (redo-SAVR). However, the utility of ViV-TAVI is poorly understood. METHODS: A systematic electronic search of the scientific literature was done in PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov. Only studies which compared the safety and efficacy of ViV-TAVI and redo-SAVR head to head in failed BP valves were included. RESULTS: Six observational studies were eligible and included 594 patients, of whom 255 underwent ViV- TAVI and 339 underwent redo-SAVR. There was no significant difference between ViV-TAVI and redo- SAVR for procedural, 30 day and 1 year mortality rates. ViV-TAVI was associated with lower risk of permanent pacemaker implantation (PPI) (OR: 0.43, CI: 0.21-0.89; P = 0.02) and a trend toward increased risk of paravalvular leak (PVL) (OR: 5.45, CI: 0.94-31.58; P = 0.06). There was no significant difference for stroke, major bleeding, vascular complications and postprocedural aortic valvular gradients more than 20 mm-hg. CONCLUSION: Our results reiterate the safety and feasibility of ViV-TAVI for failed aortic BP valves in patients deemed to be at high risk for surgery. VIV-TAVI was associated with lower risk of permanent pacemaker implantation with a trend toward increased risk of paravalvular leak.

Trends in Infective Endocarditis Mortality in the United States: 1999 to 2020: A Cause for Alarm.

BACKGROUND: Data on national trends in mortality due to infective endocarditis (IE) in the United States are limited. METHODS AND RESULTS: Utilizing the multiple causes of death data from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2020, IE and substance use were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. Between 1999 and 2020, the IE-related age-adjusted mortality rates declined. IE-related crude mortality accelerated significantly in the age groups 25-34 years (average annual percentage change, 5.4 [95% CI, 3.1-7.7]; P<0.001) and 35-44 years (average annual percentage change, 2.3 [95% CI, 1.3-3.3]; P<0.001), but remained stagnant in those aged 45-54 years (average annual percentage change, 0.5 [95% CI, -1.9 to 3]; P=0.684), and showed a significant decline in those aged ≥55 years. A concomitant substance use disorder as multiple causes of death in those with IE increased drastically in the 25-44 years age group (P<0.001). The states of Kentucky, Tennessee, and West Virginia showed an acceleration in age-adjusted mortality rates in contrast to other states, where there was predominantly a decline or static trend for IE. CONCLUSIONS: Age-adjusted mortality rates due to IE in the overall population have declined. The marked acceleration in mortality in the 25- to 44-year age group is a cause for alarm. Regional differences with acceleration in IE mortality rates were noted in Kentucky, Tennessee, and West Virginia. We speculate that this acceleration was likely due mainly to the opioid crisis that has engulfed several states and involved principally younger adults.

Safety and Feasibility of Staged Versus Concomitant Transcatheter Edge-to-Edge Mitral Valve Repair After Transcatheter Aortic Valve Implantation.

The data on the safety and feasibility of performing concomitant or staged transcatheter edge-to-edge repair (TEER) of the mitral valve with transcatheter aortic valve implantation (TAVI) remains limited. The Nationwide Readmission Database was used to identify TEER and TAVI procedures from October 1, 2015 to December 31, 2019, using the International Classification of Diseases, Tenth Revision, Clinical Modification administrative data. A total of 627 weighted cases of TEER and TAVI procedures were included in the analysis. Of those cases, 453 underwent staged TEER after TAVI, whereas 174 had concomitant TAVI and TEER during the same admission. Patients who underwent staged procedures were mostly men (64.8%, p = 0.02) and had a higher median age of 85 years (interquartile range 79 to 88) versus 82 years (interquartile range 72 to 86) in the concomitant procedure group. The adjusted propensity-matched mortality rate was similar for staged versus same-admission procedures (6.1% vs 7.0%, p = 0.79). In-hospital complication rates, including acute kidney injury, vascular complications, need for percutaneous coronary intervention, mechanical support, and pacemaker implantation, were higher for the same-admission TEER and TAVI group than TEER performed as a staged procedure. Nonhome facility discharges and length of hospital stay (15 vs 4 days) were also significantly higher for the concomitant same-admission TEER and TAVI groups. In conclusion, there was no difference in in-hospital mortality rate between patients who underwent concomitant or staged TEER and TAVI procedures, whereas complication rates were significantly higher in the concomitant group.

Longitudinal Follow-Up of Asymptomatic COVID-19 Myocarditis with Cardiac Magnetic Resonance Imaging.

BACKGROUND Varying degrees of cardiovascular involvement have been noted with COVID-19, with myocarditis being one of the feared complications. We present the case of a healthy, young individual with persistent myocardial involvement on cardiac magnetic resonance (CMR) imaging at 10 months' follow-up. CASE REPORT A 23-year-old man with no prior medical conditions presented to our outpatient cardiology clinic with a chief concern of left-sided exertional chest discomfort of 1-week duration, lasting 30-60 min before resolving. The patient was previously active and ran 2 miles per day, 6 days a week without any issues. Three months prior to presentation, the patient had a mild case of COVID-19 managed conservatively on an outpatient basis. On evaluation, the vital signs, physical examination, and laboratory work-up were unremarkable. Electrocardiography (EKG) displayed normal sinus rhythm with incomplete right bundle branch block. Transthoracic echocardiography (TTE) was normal. CMR was performed and indicated myopericarditis in several sub-epicardial and pericardial segments, with a quantitative scar burden of 18.6% on late gadolinium enhancement (LGE) images using the mean+5 SD method. A repeat CMR 7 months later demonstrated persistent sub-epicardial fibrosis with improvement in the LGE burden to 5.1% and resolution of pericarditis. CONCLUSIONS Myopericarditis with persistent myocardial scarring can be detected using CMR in healthy individuals with mild COVID-19 symptoms. The exact prevalence and potential clinical implications of this entity is unclear and warrants further longitudinal research.

A Comprehensive Review of Mechanical Circulatory Support Devices.

Treatment strategies to combat cardiogenic shock (CS) have remained stagnant over the past decade. Mortality rates among patients who suffer CS after acute myocardial infarction (AMI) remain high at 50%. Mechanical circulatory support (MCS) devices have evolved as novel treatment strategies to restore systemic perfusion to allow cardiac recovery in the short term, or as durable support devices in refractory heart failure in the long term. Haemodynamic parameters derived from right heart catheterization assist in the selection of an appropriate MCS device and escalation of mechanical support where needed. Evidence favouring the use of one MCS device over another is scant. An intra-aortic balloon pump is the most commonly used short-term MCS device, despite providing only modest haemodynamic support. Impella CP® has been increasingly used for CS in recent times and remains an important focus of research for patients with AMI-CS. Among durable devices, Heartmate® 3 is the most widely used in the USA. Adequately powered randomized controlled trials are needed to compare these MCS devices and to guide the operator for their use in CS. This article provides a brief overview of the types of currently available MCS devices and the indications for their use.

Variation in Survival After Cardiopulmonary Arrest in Cardiac Catheterization Laboratories in the United States.

BACKGROUND: In-hospital cardiac arrest during cardiac catheterization is not uncommon. The extent of variation in survival after cardiac arrest occurring in the cardiac catheterization laboratory (CCL) and underlying factors are not well known. OBJECTIVES: The aim of this study was to identify the factors associated with higher survival rates after an index cardiac arrest in the CCL. METHODS: Within the GWTG (Get With The Guidelines)-Resuscitation registry, patients ≥18 years of age who had index in-hospital cardiac arrest in the CCL between January 1, 2003, and December 31, 2017, were identified. Hierarchical models were used to adjust for demographics, comorbidities, and cardiac arrest characteristics to generate risk-adjusted survival rates (RASRs) to discharge for each hospital with ≥5 cases during the study period. Median OR was used to quantify the extent of hospital-level variation in RASR. RESULTS: The study included 4,787 patients from 231 hospitals. The median RASR was 36% (IQR: 21%) and varied from a median of 20% to 52% among hospitals in the lowest and highest tertiles of RASR, respectively. The median OR was 1.71 (95% CI: 1.52-1.87), suggesting that the odds of survival for patients with identical characteristics with in-hospital cardiac arrest in the CCL from 2 randomly chosen different hospitals varied by 71%. Hospitals with greater annual numbers of cardiac arrest cases in the CCL had higher RASRs. CONCLUSIONS: Even in controlled settings such as the CCL, there is significant hospital-level variation in survival after in-hospital cardiac arrest, which suggests an important opportunity to improve resuscitation outcomes in procedural areas.

Differential Effects of Cardiac Rehabilitation in Obese and Non-Obese Population.

Background Cardiac rehabilitation (CR) improves outcomes in patients with heart disease. We investigated the differences in outcomes of comprehensive phase II CR in obese and non-obese patients. Methods We performed a retrospective analysis of functional outcomes including metabolic equivalents (METS), heart rate (chronotropic competence - CC), and blood pressure response (BPR) in 178 patients undergoing CR based on underlying body mass index (BMI). Demographic and clinical variables were assessed for age, gender, race, smoking, hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, stroke, heart failure, medication use, and several sessions attended. Results Initial CC and METS were impaired in majority of patients attending CR, whereas BPR to exercise was mostly preserved. Significant improvement occurred in CC (non-obese: 0.71 ± 0.11 vs 0.76 ± 0.11, p < 0.001; obese: 0.72 ± 0.10 vs 0.75 ± 0.12, p = 0.0010) and METS (non-obese: 4.96 ± 1.98 vs 7.33 ± 2.94, p < 0.001; obese: 4.39 ± 1.81 vs 6.79 ± 3.34, p < 0.001). Post-CR obese patients were able to reach similar level of physical activity as non-obese patients (6.79 ± 3.34 vs 7.33 ± 2.94; p = 0.2). Improvement in BPR was only seen in non-obese patients (24.02 ± 20.07 vs 30.18 ± 21.93; p = 0.019). Improvement in functional variables occurred despite increase in BMI in non-obese (25.91 ± 2.85 vs 26.21 ± 2.96; p = 0.031), and there was no significant change in BMI in obese (35.30 ± 5.60 vs 34.93 ± 5.42; p > 0.05). Conclusion CR concurrently improves functional outcomes in both obese and non-obese patients despite no associated weight loss. The difference in BPR, however, is seen in only non-obese individuals. Future studies are needed to validate the role of weight-optimized CR protocols as a potential target for improving cardiac outcomes.

Meta-Analysis of Transradial vs Transfemoral Access for Percutaneous Coronary Intervention in Patients With ST Elevation Myocardial Infarction.

Transradial access (TRA) has emerged as an alternative to transfemoral access (TFA) for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) patients. However, the rate of TRA adoption has been much slower in the acute coronary syndrome (ACS) patient population. This meta-analysis was conducted to assess clinical outcomes of TRA compared with TFA in STEMI patients undergoing PCI. A manual search of PubMed, EMBASE, Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and recent major scientific conference sessions from inception to October 15th, 2019 was performed. Primary outcomes in our analysis were all-cause mortality and trial-defined major bleeding. Secondary outcomes included vascular complications, myocardial infarction, stroke, procedure, and fluoroscopy time. 17 randomized controlled trials (RCTs) (N = 12,018) met inclusion criteria. TRA was associated with lower all-cause mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.57 to 0.88), major bleeding (RR: 0.59, 95%CI: 0.45 to 0.77), and vascular complications (RR: 0.42, 95%CI: 0.32 to 0.56) compared with TFA. There was no difference in the incidence of myocardial infarction (MI), stroke, or procedure duration between the 2 groups. The difference in all-cause mortality between TRA and TFA was statistically nonsignificant when major bleeding was held constant. In conclusion, TRA was associated with lower risk of all-cause mortality, major bleeding, and vascular complications compared with TFA in STEMI patients undergoing PCI.

An Update on the Reversal of Non-Vitamin K Antagonist Oral Anticoagulants.

Non-vitamin K antagonist oral anticoagulants (NOACs) include thrombin inhibitor dabigatran and coagulation factor Xa inhibitors rivaroxaban, apixaban, edoxaban, and betrixaban. NOACs have several benefits over warfarin, including faster time to the achieve effect, rapid onset of action, fewer documented food and drug interactions, lack of need for routine INR monitoring, and improved patient satisfaction. Local hemostatic measures, supportive care, and withholding the next NOAC dose are usually sufficient to achieve hemostasis among patients presenting with minor bleeding. The administration of reversal agents should be considered in patients on NOAC's with major bleeding manifestations (life-threatening bleeding, or major uncontrolled bleeding), or those who require rapid anticoagulant reversal for an emergent surgical procedure. The Food and Drug Administration (FDA) has approved two reversal agents for NOACs: idarucizumab for dabigatran and andexanet alfa for apixaban and rivaroxaban. The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) have released an updated guideline for the management of patients with atrial fibrillation that provides indications for the use of these reversal agents. In addition, the final results of the ANNEXA-4 study that evaluated the efficacy and safety of andexanet alfa were recently published. Several agents are in different phases of clinical trials, and among them, ciraparantag has shown promising results. However, their higher cost and limited availability remains a concern. Here, we provide a brief review of the available reversal agents for NOACs (nonspecific and specific), recent updates on reversal strategies, lab parameters (including point-of-care tests), NOAC resumption, and agents in development.

Efficacy and safety of figure-of-eight suture versus manual pressure for venous access closure: a systematic review and meta-analysis.

BACKGROUND: Vascular hemostasis after venous access in cardiovascular procedures remains a challenge. Figure-of-eight (FoE) emerged as an alternative technique to manual pressure. However, its feasibility and safety is unknown. METHODS: A comprehensive search in clinicalTrials.gov, PubMed, Web of Science, EBSCO Services, Cochrane Central Register of Controlled Trials, Google Scholar, and various scientific conference sessions from inception to December 1, 2018, was performed. A meta-analysis was performed using random effects model to calculate risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI). RESULTS: Seven studies were eligible and included 1978 patients, of whom 982 patients received the FoE suture, while 996 received manual pressure. There was no difference in the risk of access site pseudoaneurysm (RR 0.48, 95%CI 0.13 to 1.73, p = 0.26) and fistula (RR 0.90, 95%CI 0.22 to 3.75, p = 0.89) between the two techniques. Compared with manual pressure, FoE was associated with lower risk of access site complications (RR 0.37, 95%CI 0.24 to 0.58, 0.65, p < 0.0001) including bleeding (RR 0.30, 95%CI 0.18 to 0.50, p < 0.00001) and hematoma (RR 0.41, 95%CI 0.25 to 0.68, 0.83, p = 0.0005). Time to hemostasis was significantly lower in FoE group compared with manual pressure (MD - 21.04 min, 95%CI - 35.66 to - 6.42, p = 0.005). CONCLUSIONS: The results of our meta-analysis showed that there was no difference in the risk of access site pseudoaneurysm and fistula between FoE and manual pressure. FoE was associated with lower risk of access site hematoma and bleeding compared with manual pressure. Our results reiterate the safety and feasibility of FoE suture for venous access closure.

Subclavian and Axillary Vein Access Versus Cephalic Vein Cutdown for Cardiac Implantable Electronic Device Implantation: A Meta-Analysis.

OBJECTIVES: This study sought to evaluate the efficacy and safety of venous access techniques for cardiac implantable electronic device (CIED) implantation. BACKGROUND: Minimally invasive transvenous access is a fundamental step during implantation of CIEDs. However, the preferred venous access is still subject to ongoing debate, and the decision depends on patient characteristics and operator experience. METHODS: A comprehensive search for studies comparing subclavian vein puncture (SVP) and axillary vein puncture (AVP) versus cephalic vein cutdown (CVC) for CIED implantation was performed in PubMed, Google Scholar, EMBASE, SCOPUS, ClinicalTrials.gov, and various scientific conferences from inception to July 1, 2019. A meta-analysis was performed by using a random effects model to calculate risk ratios (RRs) and mean differences with 95% confidence interval (CIs). RESULTS: Twenty-three studies were eligible that included 35,722 patients (SVP, n = 18,009; AVP, n = 409; and CVC, n = 17,304). Compared with CVC, SVP was associated with a higher risk of pneumothorax (RR: 4.88; 95% CI: 2.95 to 8.06) and device/lead failure (RR: 2.09; 95% CI: 1.07 to 4.09), whereas there was no significant difference in these outcomes compared with AVP. Acute procedural success was significantly higher with SVP compared with CVC (RR: 1.24; 95% CI: 1.00 to 1.53). There was no significant difference in other complications such as pocket hematoma/bleeding, device infection, or pericardial effusion between SVP or AVP compared with CVC. CONCLUSIONS: CVC was associated with a lower risk of pneumothorax and lead failure compared with SVP. AVP and CVC are both effective approaches for CIED lead implantation and offer the potential to avoid the complications usually observed with traditional SVP.