Significant Reduction In Major Adverse Cardiovascular Events Research Articles

Safety and Efficacy of Colchicine in Patients With Coronary Artery Disease: A Systematic Review and Meta-Analysis

BackgroundGiven current evidence, the use of colchicine for the prevention of adverse cardiovascular events in patients with coronary artery disease (CAD) remains controversial. MethodsMultiple databases were queried to identify studies comparing the safety and efficacy of colchicine in patients with acute coronary syndrome (ACS) or stable angina. The relative risk (RR) of major adverse cardiovascular events (MACE) and gastrointestinal (GI) adverse events were calculated using a random-effect model. ResultsSix clinical trials comprising a total of 5820 patients were identified. The pooled RR of MACE (0.64, 95% confidence interval (CI) 0.36–1.14, p = 0.13), ACS (0.62, 95% CI 0.27–1.41, p = 0.25), cardiac arrest (0.74, 95% CI 0.26–2.14, p = 0.58), stent restenosis (0.71, 95% CI 0.41–1.23, p = 0.22) and mortality (0.95, 95% CI 0.63–1.42, p = 0.79) with colchicine was not significantly different from placebo or control groups. The overall RR of revascularization (0.53, 95% CI 0.34–0.83, p = 0.005) and stroke (0.26, 95% CI 0.11–0.62, p = 0.002) was significantly lower while the net RR of GI adverse events was significantly higher (HR 2.66, 95% CI 1.21–5.87, p = 0.02) in the colchicine group. Propensity matched cohort, sensitivity and subgroup analysis based on adjusted MACE and dosages of colchicine all mirrored the overall results. ConclusionIn patients with CAD presenting with an acute coronary syndrome or stable angina, colchicine might offer no significant reduction in MACE and could potentially be harmful due to a significantly higher risk of GI-related adverse events.

Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease

A strategy of complete revascularization (CR) versus infarct-related artery revascularization (IRA) in patients with ST-elevation myocardial infarction (STEMI) continues to be a subject of debate. We performed an updated meta-analysis to compare the 2 strategies. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, stroke, repeat revascularization, myocardial infarction, and contrast-induced nephropathy. Ten randomized trials including 7,423 patients (CR = 3,574 and IRA = 3,849), with a follow-up of 2.0±0.8 years were included. There was a significant reduction in MACE with CR versus IRA (10.7% vs 18.6%, relative risk [RR] 0.64, 95% confidence interval [CI] 0.51 to 0.81, p = 0.002, I2 = 66%), with higher risk reduction with immediate versus stages revascularization (RR 0.40, 95% CI 0.32 to 0.5 vs RR 0.69, 95% CI 0.54 to 0.89, P-interaction = 0.002). Complete revascularization was associated with lower rates of repeat revascularization (4.0% vs 11.7%, RR 0.44, 95% CI 0.28 to 0.70, p<0.0001, I2 = 81%), and a nonsignificant trend toward lower cardiovascular mortality (2.8% vs 3.7%, RR 0.78, 95% CI 0.60 to 1.03, p = 0.08, I2 = 0%). However, there was no difference between the 2 strategies in all-cause mortality (4.6% vs 4.8%, RR 0.90, 95% CI 0.73 to 1.12, p = 0.36, I2 = 0%), myocardial infarction (5.2% vs 6.5%, RR 0.73, 95% CI, 0.58 to 1.08, p = 0.08, I2 = 30%), stroke (1.5% vs 1.2%, RR 1.14, 95% CI 0.56 to 2.29, p = 0.33, I2 = 14%), or contrast-induced nephropathy (1.6% vs 1.2%, RR 1.35, 95% CI 0.85 to 2.15, p = 0.78, I2 = 0%). In conclusion, CR in patients with STEMI is associated with significant reduction in MACE compared with IRA. This reduction is derived mainly by the low rates of repeat revascularization in the CR group.

Glucagon-like peptide-1 receptor agonists and cardiovascular outcomes in patients with and without prior cardiovascular events: An updated meta-analysis and subgroup analysis of randomized controlled trials.

To conduct a meta-analysis of cardiovascular outcome trials on the effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on major adverse cardiovascular events (MACE). A search of MEDLINE, EMBASE, Cochrane database and clinicaltrials.gov was performed to identify controlled trials (up to 15 June 2019) of GLP-1RAs with a cardiovascular endpoint. The principal endpoint of the present meta-analysis was MACE; secondary endpoints included myocardial infarction, stroke, cardiovascular and all-cause mortality, and hospitalization for heart failure. Mantel-Haenszel odds ratios (MH-ORs) with 95% confidence intervals (CIs) were calculated for all outcomes. In the seven trials included, all placebo-controlled, GLP-1RA treatment was associated with a reduction in MACE (MH-OR 0.87 [95% CI 0.81, 0.93]). Cardiovascular and all-cause mortality, myocardial infarction and stroke were also reduced (MH-OR 0.88 [95% CI 0.80, 0.96], MH-OR 0.90 [95% CI 0.82, 0.98], MH-OR 0.91 [95% CI 0.84, 0.98] and MH-OR 0.86 [95% CI 0.77, 0.97], respectively). Results for hospitalization for heart failure were not statistically significant (MH-OR 0.93 [95% CI 0.83, 1.04]). The meta-analyses of patient subgroups showed a significant reduction in MACE with GLP-1RAs, irrespective of gender, advanced age and obesity. GLP-1RAs are associated with a reduction in cardiovascular morbidity and mortality in high-risk patients with diabetes. This effect does not appear to be moderated by gender or body mass index. The possibility of different effects of GLP-1RAs between patients in primary and secondary prevention merits further investigation.

Intravascular ultrasound versus angiography-guided drug-eluting stent implantation in patients with complex coronary lesions: An updated meta-analysis of nine randomized clinical trials.

Objective:Intravascular ultrasound (IVUS) is not routinely performed in the real-world practice, and the benefits of IVUS-guided drug-eluting stent (DES) implantation in patients with complex coronary lesions remains unclear. This updated meta-analysis attempts to evaluate the clinical outcomes of the IVUS guidance in these patients.Methods:We searched potential eligible citations from the PubMed, EMBASE, Medline, and other internet sources. The primary endpoint were major adverse cardiovascular events (MACE), including cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR). The risk of definite/probable stent thrombosis (ST) was chosen as the safety endpoint.Results:Nine randomized trials including a total of 3,612 patients with complex coronary lesions were finally analyzed. Compared to angiography guidance, IVUS-guided DES implantation was associated with significantly lower incidence of MACE [odds ratios (OR) 0.57, 95% confidence intervals (CI): 0.45–0.72, p<0.001; I2=0.0%, p=0.674], cardiac death (OR 0.42, 95%CI:0.21–0.82, p=0.010; I2=0.0%, p=0.961), MI (OR 0.65, 95%CI:0.44–0.95, p=0.027; I2=41.8%, p=0.089), TVR (OR 0.55, 95%CI:0.38–0.79, p=0.001; I2=0.0%, p=0.916), target lesion revascularization (TLR) (OR 0.58, 95%CI:0.41–0.82, p=0.002; I2=0.0%, p=0.888), and ST (OR 0.48, 95%CI:0.24–0.93, p=0.029; I2=0.0%, p=0.733).Conclusion:The updated meta-analysis demonstrates that DES implantation under IVUS guidance leads to a significant reduction in MACE, cardiac death, MI, TVR, TLR, and ST among patients with complex coronary lesions.

Follow up of Complete Revascularization versus Culprit Revascularization in ST Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Objectives: To compare between only Culprit revascularization versus total revascularization in patients with ST-elevation myocardial infarction undergoing primary PCI with 6 months follow up of occurrence of major adverse cardiovascular events (MACCE). Methods: 50 patients were enrolled in this study during the period from 1/11/2018 to 1/11/2019 at Menoufiya University and national heart institute. All patients present with acute ST-elevation myocardial infarction within 24 hours of onset of symptoms, and have multi vessel coronary artery disease on angiography suitable for PCI. Patients were subjected to detailed medical history, physical examination, and electrocardiography. Results: 50 patients with acute ST-elevation myocardial infarction (28 females and 22 males) underwent primary percutaneous coronary intervention. 25 patients had total revascularization to all coronary arteries, the other 25 patients had only culprit revascularization. We found that there was a significant reduction in the incidence of recurrent chest pain and non-fatal Myocardial infarction in the total revascularization group. Conclusion: Our study showed that Multivessel revascularization resulted in an improved clinical course and a significant reduction of MACCE regarding non-fatal MI and a significant reduction of recurrent chest pain.

Drug-Eluting Versus Bare-Metal Stents in Older Patients: A Meta-Analysis of Randomized Controlled Trials.

Despite the high prevalence of ischemic heart disease in older patients, there is a substantial lack of evidence to guide clinical decision-making in this population. Hence, we performed a meta-analysis to determine the safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus bare-metal stents (BMS). Electronic databases were searched for randomized trials comparing DES with BMS in patients ≥70 years-old. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included different ischemic and bleeding events. Subgroup analyses for dual-antiplatelet therapy (DAPT) duration were conducted. We included 7 trials with a total of 5449 patients. The use of DES compared with BMS was associated with a significant reduction in MACE (odds ratio [OR]:0.76; 95% confidence interval [CI]:0.62-0.93; P = 0.007) with no increased risk of bleeding events (OR: 1.07; 95% CI: 0.89-1.27; P = 0.48). However, longer duration of DAPT (>6 months) for the DES group increased bleeding events (OR: 1.52; 95% CI: 1.05-2.20; P = 0.03). In contrast, shorter DAPT showed persistent efficacy in reducing MACE in DES-treated patients with no increased bleeding events (OR: 0.72; 95% CI: 0.60-0.87; P < 0.01 and OR: 1.01; 95% CI: 0.84-1.22; P = 0.89, respectively). In older patients who had undergone PCI, DES showed superior efficacy in reducing MACE with no increased risk of bleeding compared with BMS. Persistent MACE reduction was evident with shorter DAPT durations in DES-treated patients. This meta-analysis of randomized clinical trials demonstrated that drug-eluting stents were associated with a significant reduction in major adverse cardiovascular events with no increased risk of bleeding compared with bare-metal stents. The risk of bleeding was high with longer dual antiplatelet therapy duration for patients who underwent DES placement. However, short duration of dual antiplatelet therapy substantially reduced major adverse cardiovascular events with no increased bleeding risk.

Influence of radial versus femoral access site on coronary angiography and intervention outcomes: A systematic review and meta-analysis.

Systematic review and meta-analysis of randomized clinical trials (RCT) to compare procedural outcomes between radial access (RA) and femoral access (FA). Recent RCTs suggest RA for coronary angiography and percutaneous coronary intervention reduces bleeding complications, but controversy exists regarding other benefits and risks relative to FA. Searches of MEDLINE, EMBASE, CENTRAL, LILACS, and major conference abstracts identified relevant studies published from 1985-2016. We qualitatively evaluated study methodology and risk of bias. Quantitative data were abstracted relevant to the primary endpoints of major adverse cardiovascular events (MACE) and major bleeding (MB), and secondary outcomes including vascular complications and procedural failure. We identified 2,098 titles, from which 48 studies with 29,446 patients met inclusion criteria for our analysis. We found there was a significant reduction of MACE with RA versus FA (RR 0.86, 95% CI 0.77-0.95, I2 = 0%), driven by a reduction in death, but not MI or stroke. MB occurred less frequently with RA (RR 0.54, 95% CI 0.44-0.67, I2 = 4%). Vascular complications were also reduced with RA (RR 0.39, 95% CI 0.25-0.59, I2 = 75%), while procedural failure was more common (RR 2.15, 95% CI 1.65-2.82, I2 = 53%), although there was significant statistical heterogeneity for both of these outcomes. Most studies demonstrated low risk of selection and attrition biases, but high risk of detection bias. Radial access reduces the risk of death, major bleeding, and vascular complications as compared to femoral access but increases the risk of procedural failure. © 2017 Wiley Periodicals, Inc.

Safety and efficacy of anti-thrombotic regimens in patients with percutaneous coronary intervention requiring oral anticoagulation: A traditional and network meta-analysis.

Previous reports have been inconsistent in generating a consensus for optimal treatment strategy for patients with percutaneous coronary intervention (PCI) who also require oral anticoagulation (OAC). We conducted a traditional and network meta-analysis to evaluate the safety and efficacy of anti-thrombotic regimens in this subset of patients. 30 articles were recovered through preferred reporting items for systematic reviews and meta-analyses (PRISMA) using MEDLINE, EMBASE and Cochrane Central Register of Controlled Clinical Trials (CENTRAL) from inception to December 2016. Dual antiplatelet therapy (DAPT) was found to be the safest treatment modality when compared to triple therapy (TT) or combination of OAC and single antiplatelet agent (OAC+SAP) [Major bleeding: (DAPT vs OAC+SAP: odds ratio (OR), 0.53; 95% credible interval (CrI), 0.30-0.91) (DAPT vs TT: OR, 0.45; 95% CrI, 0.31-0.64)]. There were no significant differences in major adverse cardiovascular events (MACE), myocardial infarction (MI), cardiovascular (CV) or total survival, stent thrombosis or target vessel revascularization (TVR) amongst the three treatment arms. TT was ranked superior for stroke reduction (SUCRA, 69%) followed by OAC+SAP and DAPT. When traditional analysis was adjusted for randomized data, OAC+SAP was equivalent to TT with regards to stroke (OR, 0.74; 95% confidence interval (CI), 0.38-1.46; p=0.39) and showed significant reduction in MACE and total mortality. DAPT was found to be the safest and equally effective regimen when compared to TT and OAC+SAP. However this strategy bears considerable risk to patients with high thromboembolic risk. This issue can be encountered by using OAC+SAP as an alternative of TT in patients with intermediate to high stroke risk and intermediate to high bleeding propensity.

Outcomes with First and Second-Generation Drug-Eluting Stents in Intravascular Ultrasound-Guided Stent Implantation: A Meta-Analysis

Background: Recent research has shown clinical benefits with intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in comparison with angiography guidance alone. However, it remains unclear if the benefit of IVUS-guided implantation is the same regardless of stent generation. We performed a systematic review and meta-analysis of trials studying IVUS and specifying outcomes of patients who received first and/or second-generation stents. Methods: Studies that reported clinical outcomes and compared first- and second-generation stents implanted with IVUS or angiography guidance were included. Peto analysis was used to estimate effect size. Results: Fifteen studies with a total of 9,313 patients were included; 4,592 patients underwent IVUS-guided and 4,721 angiography-guided PCI. Comparison of IVUS- and angiography-guided PCI for first-generation stents yielded an odds ratio (OR) of 0.79 (95% confidence interval 0.67-0.92) favouring IVUS guidance for major adverse cardiovascular events (MACE). In contrast, the same comparison for second-generation stents yielded an OR of 0.57 (95% confidence interval 0.43-0.77) for MACE. IVUS-guided PCI was associated with a significant reduction in target lesion revascularisation (OR 0.66; 95% confidence interval 0.52-0.84) and stent thrombosis (OR 0.52; 95% confidence interval 0.38-0.72) in both stent generations. Conclusions: IVUS-guided PCI is associated with a significant reduction in MACE when utilised during PCI with both first- and second-generation DES stents. These data should support the use of IVUS-guided PCI for contemporary revascularisation procedures.

Abstract 15079: Complete Revascularization for Multivessel Disease ST Elevation Myocardial Infarction: Insights From an Updated Meta-Analysis

Introduction: Multivessel Disease is commonly seen in ST Elevation Myocardial Infarction (STEMI). Current guidelines recommend primary percutaneous coronary intervention (PCI) on only the culprit vessel , unless the patient is hemodynamically unstable. Recent trials have reported significant benefit on cardiovascular endpoints with complete revascularization of vessels during STEMI. The purpose of this meta analysis was to assess the benefit of complete revascularization (either single setting or staged PCI) compared to culprit only PCI in STEMI patients with multivessel disease. Methods: We searched PubMed, The Cochrane Library, EMBASE, EBSCO, Web of Science ,CINAHL databases and presentations at major cardiovascular scientific sessions from inception through June 5th, 2015. Randomized Trials comparing complete revascularization strategies (single-setting PCI or staged PCI) and culprit-only PCI were included. The primary outcome of interest was major adverse cardiovascular events (MACE) defined as a composite of all-cause mortality, new myocardial infarction (MI) and repeat revascularization. Results: Seven trials enrolling a total of 2006 patients were included in the final analysis. Complete revascularization (single-setting PCI + staged PCI) was associated with a significant reduction in MACE, when compared to culprit only PCI [OR 0.52; 95 % CI 0.32 to 0.85; P = 0.009]. However, there was no significant difference in all cause mortality [OR 0.75; 95 % CI 0.51 to 1.12] or recurrent MI [OR 0.74;95 % CI 0.4 to 1.39] with complete revascularization. Conclusion: In patients with STEMI and multivessel disease, complete revascularization is associated with a significant reduction in major adverse cardiovascular outcomes, driven primarily by a reduction in repeat revascularization, with no evidence of significant difference in all cause mortality or recurrent MI when compared to culprit only PCI.