Cell therapy for nonischemic dilated cardiomyopathy: A systematic review and meta-analysis of randomized controlled trials.

Cell therapy involves transplantation of human cells to promote repair of diseased or injured tissues and/or cells. Only a limited number of mostly small-scale trials have studied cell therapy in nonischemic cardiomyopathy (NICM). We performed a meta-analysis of randomized clinical trials (RCTs) to assess the safety and efficacy of cell therapy in NICM. Electronic databases were searched for relevant RCTs from inception until August 2020. Outcomes assessed were left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter or volume (LVEDD), quality of life (QoL) indices, and major adverse cardiac events (MACEs). Weighted mean differences (MDs) and standardized mean differences (SMDs) were calculated using random-effects methods. Eleven RCTs with 574 participants were included in the analysis. There was a significant increase in mean LVEF (MD, 4.17%; 95% confidence interval [CI] = 1.66-6.69) and modest decrease in LVEDD (SMD, -0.50; 95% CI = -0.95 to -0.06) in patients treated with cell therapy compared with controls. Cell therapy was also associated with improvement in functional capacity, as assessed by the 6-minute walking distance (MD, 72.49 m; 95% CI = 3.44-141.53). No significant differences were seen in MACEs and QoL indices between treated and control groups. This meta-analysis suggests that cell therapy may improve LV systolic function and may be associated with improvement in LVEDD and functional capacity compared with maximal medical therapy. Cell therapy was safe, with no significant difference in MACEs between treatment and control groups. However, given the limitations of current studies, larger well-designed RCTs are needed to evaluate the efficacy of cell therapy in patients with NICM.

Meta-Analysis Comparing Endovascular Treatment Modalities for Femoropopliteal Peripheral Artery Disease.

Endovascular interventions are commonly utilized for treatment of femoropopliteal peripheral artery disease. The relative efficacy of these interventions remains unclear. A Bayesian network meta-analysis was performed comparing 5 endovascular treatment modalities: balloon angioplasty (BA), bare metal stent (BMS), covered stent (CS), drug-coated balloon (DCB), drug-eluting stent (DES) for femoropopliteal peripheral artery disease. The primary efficacy end points were freedom from target lesion revascularization (TLR) and primary patency at 12 months. BA was the reference treatment. Twenty-two trials including 4,381 participants provided data on TLR. Sixteen trials including 3,691 participants provided data on primary patency. Point estimates for DCB suggested that it was the most efficacious treatment for freedom from TLR (odds ratio [OR] 4.23; 95% credible intervals [CrI] 2.43 to 7.66) followed by CS (OR 3.65; 95% CrI 1.11 to 12.55), DES (OR 2.64; 95% CrI 0.72 to 9.77), and BMS (OR 2.3; 95% CrI 1.11 to 4.76). Similarly, point estimates for primary patency were highest with DES (OR 8.93; 95% CrI 3.04, 27.14) followed by CS (OR 3.91; 95% CrI 1.18, 13.84), DCB (OR 3.32; 95% CrI 1.8, 6.25), and BMS (OR 3.5; 95% CrI 1.58, 7.99). In conclusion, DCB has the lowest need for TLR whereas DES has the highest primary patency rate. DCB, CS, and BMS were associated with significant reductions in TLR compared with BA, whereas DCB, DES, CS, and BMS were associated with significantly improved primary patency compared with BA.

Global, Regional, and National Burden of Calcific Aortic Valve and Degenerative Mitral Valve Diseases, 1990-2017.

BACKGROUND: Nonrheumatic valvular diseases are common; however, no studies have estimated their global or national burden. As part of the Global Burden of Disease Study 2017, mortality, prevalence, and disability-adjusted life-years (DALYs) for calcific aortic valve disease (CAVD), degenerative mitral valve disease, and other nonrheumatic valvular diseases were estimated for 195 countries and territories from 1990 to 2017. METHODS: Vital registration data, epidemiologic survey data, and administrative hospital data were used to estimate disease burden using the Global Burden of Disease Study modeling framework, which ensures comparability across locations. Geospatial statistical methods were used to estimate disease for all countries, because data on nonrheumatic valvular diseases are extremely limited for some regions of the world, such as Sub-Saharan Africa and South Asia. Results accounted for estimated level of disease severity as well as the estimated availability of valve repair or replacement procedures. DALYs and other measures of health-related burden were generated for both sexes and each 5-year age group, location, and year from 1990 to 2017. RESULTS: Globally, CAVD and degenerative mitral valve disease caused 102 700 (95% uncertainty interval [UI], 82 700-107 900) and 35 700 (95% UI, 30 500-42 500) deaths, and 12.6 million (95% UI, 11.4 million-13.8 million) and 18.1 million (95% UI, 17.6 million-18.6 million) prevalent cases existed in 2017, respectively. A total of 2.5 million (95% UI, 2.3 million-2.8 million) DALYs were estimated as caused by nonrheumatic valvular diseases globally, representing 0.10% (95% UI, 0.09%-0.11%) of total lost health from all diseases in 2017. The number of DALYs increased for CAVD and degenerative mitral valve disease between 1990 and 2017 by 101% (95% UI, 79%-117%) and 35% (95% UI, 23%-47%), respectively. There is significant geographic variation in the prevalence, mortality rate, and overall burden of these diseases, with highest age-standardized DALY rates of CAVD estimated for high-income countries. CONCLUSIONS: These global and national estimates demonstrate that CAVD and degenerative mitral valve disease are important causes of disease burden among older adults. Efforts to clarify modifiable risk factors and improve access to valve interventions are necessary if progress is to be made toward reducing, and eventually eliminating, the burden of these highly treatable diseases.

Comparison of revascularization strategies in patients with acute coronary syndrome and multivessel coronary disease: A systematic review and network meta-analysis.

BACKGROUND: Whether revascularization should be performed as multivessel intervention at the time of index procedure (MV-index), staged procedure (MV-staged), or culprit only intervention (COI) in patients with multivessel disease (MVD) presenting with acute coronary syndrome (ACS) is unclear. We performed a systematic review and network meta-analysis of randomized controlled trials to assess the optimal revascularization strategy in this patient population. METHODS: PubMed, Embase, and Cochrane Central databases were systematically searched to identify all relevant studies. The outcomes assessed were major cardiac adverse events (MACE), all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and revascularization. A Bayesian random-effects network meta-analysis was used to calculate odds ratio (OR) with credible interval (CrI). RESULTS: Thirteen studies with 8,066 patients were included in the analysis. There was a decreased risk of MACE (MV-index vs. COI: OR, 0.35; 95% CrI, 0.23-0.55; MV-staged vs COI: OR, 0.52; 95% CrI, 0.31-0.81) and revascularization (MV-index vs. COI: OR, 0.27; 95% CrI, 0.15-0.49; MV-staged vs. COI: OR, 0.38; 95% CrI, 0.19-0.70) with MV-index intervention and MV-staged intervention compared with COI. However, MV-index intervention and not MV-staged intervention was associated with a decreased risk of MI (MV-index vs. COI: OR, 0.35; 95% CrI, 0.12-0.93; MV-staged vs. COI: OR, 0.65; 95% CrI, 0.24-1.59) compared with COI. CONCLUSIONS: Our analysis suggests that multivessel intervention either at index procedure or as staged intervention may be more efficacious compared to COI in patients with MVD presenting with ACS.

Prasugrel vs. Ticagrelor for Acute Coronary Syndrome Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis.

BACKGROUND: The newer P2Y12 inhibitors have better efficacy than clopidogrel. However, whether ticagrelor or prasugrel have a better comparative safety and efficacy profile, especially in the long-term, remains inconclusive. OBJECTIVE: We compared prasugrel and ticagrelor in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). METHODS: MEDLINE and the Cochrane library were queried for randomized controlled trials (RCTs) or observational studies comparing prasugrel with ticagrelor in patients with ACS undergoing PCI. Random-effects pooling was used to calculate odds ratios (ORs) with 95% confidence intervals (CI). Analyses were stratified by duration of follow-up (short term [≤ 3 months] and long term [≥ 1 year]) and study design. RESULTS: In total, 14 studies (six RCTs, eight observational studies), including 40,188 patients, met eligibility criteria. Pooled analysis did not indicate that prasugrel significantly decreased all-cause mortality compared with ticagrelor in the short term (OR 0.49; 95% CI 0.20-1.20; p = 0.11) or long term (OR 0.74; 95% CI 0.48-1.15; p = 0.38). Pooled observational studies showed significantly lower long-term all-cause mortality (OR 0.63; 95% CI 0.43-0.92; p = 0.02) and short-term stent thrombosis (OR 0.46; 95% CI 0.28-0.75; p = 0.002) with prasugrel. No significant difference was observed in the risk of nonfatal myocardial infarction, ischemic stroke, bleeding, or repeat revascularization between the two groups. Results remained similar after stratification according to follow-up and study design. CONCLUSIONS: The present analysis suggests that prasugrel might have a better efficacy profile than ticagrelor in patients with ACS undergoing PCI. However, this advantage was only seen in pooled observational studies and is likely to be affected by selection bias.

Oxygen Administration Does Not Influence the Prognosis of Acute Myocardial Infarction: A Meta-Analysis.

BACKGROUND: The safety and efficacy of supplemental oxygen in acute myocardial infarction (AMI) remains unclear. STUDY QUESTION: To evaluate the safety and efficacy of supplemental oxygen in patients who present with AMI. DATA SOURCES: We systematically searched PubMed, Embase, Cochrane Central Register of Controlled Trials, ISI Web of Science, Scopus, and conference proceedings from inception through January 2016. STUDY DESIGN: Eligible studies were randomized trials that evaluated the role of oxygen compared with room air in AMI. The clinical outcome measured was 30-day mortality, and odds ratio (OR) was calculated for the measured outcome. The Mantel-Haenszel method was used to pool 30-day mortality in a random-effects model. Sensitivity analysis was carried out to evaluate the effect of revascularization of the culprit artery on the outcome. RESULTS: The pooled analysis suggested no difference in 30-day mortality [OR 1.09; 95% confidence interval (CI), 0.30-4.00; P = 0.89] between oxygen and room air. Metaregression demonstrated that all the between-study variance was because of coronary revascularization (P = 0.01, R = 1.0). A subgroup analysis suggested a trend toward increased mortality with oxygen (OR 3.26; 95% CI, 0.94-11.29; P = 0.06) when less than half of the patient population underwent revascularization. On the other hand, there was a nonsignificant numerical decrease in mortality with oxygen (OR 0.41; 95% CI, 0.14-1.19; P = 0.10) in the presence of coronary revascularization. Metaregression confirmed that all the between-study variance was because of coronary revascularization (P = 0.01, R = 1.0). CONCLUSIONS: In this meta-analysis, we found that the evidence on the safety and efficacy of oxygen was not only weak and inconsistent but also had modest statistical power. The variation in results was mainly because of the presence or absence of revascularization of the culprit artery. Adequately powered studies are needed to further delineate the role of oxygen in patients undergoing coronary revascularization.

Meta-analysis Comparing Culprit Vessel Only Versus Multivessel Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction and Cardiogenic Shock.

Cardiogenic shock (CS) after a myocardial infarction continues to be associated with high mortality. Whether percutaneous coronary intervention (PCI) of noninfarct coronary arteries (multivessel intervention [MVI]) improves outcomes in CS after acute myocardial infarction (AMI) remains controversial. MEDLINE, Cochrane CENTRAL, and Scopus databases were searched for original studies comparing MVI with culprit-vessel intervention (CVI) in AMI patients with multivessel disease and CS. Risk ratios (RRs) and 95% confidence intervals were calculated and pooled using a random effects model. Thirteen studies, consisting of 7,906 patients (nMVI = 1,937; nCVI = 5,969), were included in this meta-analysis. Overall, the MVI and CVI groups did not differ significantly in the risk of short-term mortality (RR: 1.06 [0.91, 1.23]; p = 0.45; I2 = 75.82%), long-term mortality (RR: 0.93 [0.78, 1.11]; p = 0.37; I2 = 67.92%), reinfarction (RR: 1.16 [0.75, 1.79]; p = 0.50; I2 = 0%), revascularization (RR: 0.84 [0.48, 1.47]; p = 0.54; I2 = 83.01%), bleeding (RR: 1.15 [0.96, 1.38]; p = 0.09, I2 = 0%), or stroke (RR: 1.29 [0.86, 1.94]; p = 0.80, I2 = 0%). However, significantly increased risk of renal failure was seen in the MVI group (RR: 1.35 [1.10, 1.66]; p = 0.004; I2 = 0%). On subgroup analysis, it was seen that results from retrospective studies showed higher short-term mortality in the MVI group in comparison with prospective studies (p = 0.003). The certainty in estimates is low due to the largely observational nature of the evidence. In conclusion, MVI provides no additional reduction in short- or long-term mortality in AMI patients with multivessel disease and CS. Additionally, the risk of renal failure may be higher with the use of MVI.

Current Society of Thoracic Surgeons Model Reclassifies Mortality Risk in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: The Society of Thoracic Surgeons (STS) scores are used to screen patients for transcatheter aortic valve replacement (TAVR). The STS scores were also used to risk stratify patients in major TAVR trials. This study evaluates the reclassification of predicted risk of mortality by the currently available online STS score calculator compared with the 2008 STS risk model in patients undergoing TAVR. METHODS AND RESULTS: All patients who underwent TAVR from 2006 to 2016 were included in the study. The STS scores for all included patients were calculated by applying the 2008 STS risk model and again using the current STS online calculator. Among 1209 patients who underwent TAVR, 30-day mortality was 27 (2.2%). The overall predicted risk of mortality estimated by using the current online STS risk calculator was significantly lower than the 2008 STS risk model (6.3±4.4 vs 7.3±4.9; P<0.001). A total of 235 (19%) patients were reclassified into a lower risk category per the current STS risk model. In a multivariable logistic regression analysis, patients with persistent atrial fibrillation (odds ratio, 1.4; 95% CI, 1.0-1.9; P=0.03), chronic heart failure (odds ratio, 6.0; 95% CI, 3.8-10.1; P<0.001), and New York Heart Association class IV heart failure (odds ratio, 2.4; 95% CI, 1.3-4.4; P=0.007) were more likely to be reclassified into a lower risk category per the current STS risk model. CONCLUSIONS: The current STS calculation method produces significantly lower predicted risk of mortality than the 2008 calculator, more pronounced in patients with certain comorbid conditions. These results should be considered while evaluating data from prior studies of TAVR.

Single-Center Retrospective Study of Risk Factors and Predictive Value of Framingham Risk Score of Patients with ST Elevation Myocardial Infarction.

OBJECTIVES: The objective of this study was to identify risk factors and clinical profile of the patients presenting with ST elevation myocardial infarction (STEMI). We further evaluated the utility of the Framingham Risk Score (FRS) in the accurate identification of these patients if used before their coronary event. METHODS: We evaluated the demographic, clinical, and angiographic characteristics of patients admitted with STEMI. We also calculated cardiovascular event risk using the FRS in a subset of patients without prior known coronary artery disease and diabetes mellitus. RESULTS: A total of 44 patients, predominantly men (75%) and white (80%), with a mean age of 56 ± 10 years, were included in our analysis. Cigarette smoking was the predominant risk factor (83%) followed by hypertension (77%) and dyslipidemia (68%). The calculated FRS in a subset of patients without prior coronary artery disease or diabetes mellitus was 14.1% ± 5.8%. Based on the FRS, 8 (36%) patients had a 10-year risk >20% and 14 (63%) patients had a 10-year risk between 10% and 20%. CONCLUSIONS: In a series of consecutive patients with STEMI, we observed that high FRS was inadequate in correct identification and risk stratification of the majority of patients who had STEMI. Our study underlines the importance of being familiar with multiple risk scores and choosing the most applicable risk score based on the patient's individual characteristics. In addition, it is important to take into consideration the nontraditional risk factors or measurement of coronary artery calcium as a part of the risk assessment algorithm.

The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States.

Introduction: Several studies have measured health outcomes in the United States, but none have provided a comprehensive assessment of patterns of health by state. Objective: To use the results of the Global Burden of Disease Study (GBD) to report trends in the burden of diseases, injuries, and risk factors at the state level from 1990 to 2016. Design and Setting: A systematic analysis of published studies and available data sources estimates the burden of disease by age, sex, geography, and year. Main Outcomes and Measures: Prevalence, incidence, mortality, life expectancy, healthy life expectancy (HALE), years of life lost (YLLs) due to premature mortality, years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 333 causes and 84 risk factors with 95% uncertainty intervals (UIs) were computed. Results: Between 1990 and 2016, overall death rates in the United States declined from 745.2 (95% UI, 740.6 to 749.8) per 100 000 persons to 578.0 (95% UI, 569.4 to 587.1) per 100 000 persons. The probability of death among adults aged 20 to 55 years declined in 31 states and Washington, DC from 1990 to 2016. In 2016, Hawaii had the highest life expectancy at birth (81.3 years) and Mississippi had the lowest (74.7 years), a 6.6-year difference. Minnesota had the highest HALE at birth (70.3 years), and West Virginia had the lowest (63.8 years), a 6.5-year difference. The leading causes of DALYs in the United States for 1990 and 2016 were ischemic heart disease and lung cancer, while the third leading cause in 1990 was low back pain, and the third leading cause in 2016 was chronic obstructive pulmonary disease. Opioid use disorders moved from the 11th leading cause of DALYs in 1990 to the 7th leading cause in 2016, representing a 74.5% (95% UI, 42.8% to 93.9%) change. In 2016, each of the following 6 risks individually accounted for more than 5% of risk-attributable DALYs: tobacco consumption, high body mass index (BMI), poor diet, alcohol and drug use, high fasting plasma glucose, and high blood pressure. Across all US states, the top risk factors in terms of attributable DALYs were due to 1 of the 3 following causes: tobacco consumption (32 states), high BMI (10 states), or alcohol and drug use (8 states). Conclusions and Relevance: There are wide differences in the burden of disease at the state level. Specific diseases and risk factors, such as drug use disorders, high BMI, poor diet, high fasting plasma glucose level, and alcohol use disorders are increasing and warrant increased attention. These data can be used to inform national health priorities for research, clinical care, and policy.

The Burden of Cardiovascular Diseases Among US States, 1990-2016.

Importance: Cardiovascular disease (CVD) is the leading cause of death in the United States, but regional variation within the United States is large. Comparable and consistent state-level measures of total CVD burden and risk factors have not been produced previously. Objective: To quantify and describe levels and trends of lost health due to CVD within the United States from 1990 to 2016 as well as risk factors driving these changes. Design, Setting, and Participants: Using the Global Burden of Disease methodology, cardiovascular disease mortality, nonfatal health outcomes, and associated risk factors were analyzed by age group, sex, and year from 1990 to 2016 for all residents in the United States using standardized approaches for data processing and statistical modeling. Burden of disease was estimated for 10 groupings of CVD, and comparative risk analysis was performed. Data were analyzed from August 2016 to July 2017. Exposures: Residing in the United States. Main Outcomes and Measures: Cardiovascular disease disability-adjusted life-years (DALYs). Results: Between 1990 and 2016, age-standardized CVD DALYs for all states decreased. Several states had large rises in their relative rank ordering for total CVD DALYs among states, including Arkansas, Oklahoma, Alabama, Kentucky, Missouri, Indiana, Kansas, Alaska, and Iowa. The rate of decline varied widely across states, and CVD burden increased for a small number of states in the most recent years. Cardiovascular disease DALYs remained twice as large among men compared with women. Ischemic heart disease was the leading cause of CVD DALYs in all states, but the second most common varied by state. Trends were driven by 12 groups of risk factors, with the largest attributable CVD burden due to dietary risk exposures followed by high systolic blood pressure, high body mass index, high total cholesterol level, high fasting plasma glucose level, tobacco smoking, and low levels of physical activity. Increases in risk-deleted CVD DALY rates between 2006 and 2016 in 16 states suggest additional unmeasured risks beyond these traditional factors. Conclusions and Relevance: Large disparities in total burden of CVD persist between US states despite marked improvements in CVD burden. Differences in CVD burden are largely attributable to modifiable risk exposures.

Surface modification and evaluation of bacterial cellulose for drug delivery.

The current study was designed to prepare surface modified BC matrices loaded with model drugs selected on the basis of their aqueous solubility, i.e., poorly water soluble famotidine and highly water soluble tizanidine. Fourier transform infrared (FT-IR) spectroscopy, X-ray diffraction (XRD), scanning electron microscopy (SEM) and thermogravimetric analysis (TGA) confirmed the successful drug loading and thermal stability of the BC matrices. In-vitro dissolution studies using USP type-II dissolution apparatus showed that most of the drug was released in 0.5-3h from famotidine loaded matrices and in 0.25-0.5h from tizanidine loaded matrices. The chemical structure, concentration of the loaded drug, concentration of the surface modifier, and pre- and post-drug loading modifications altered the physicochemical properties of BC matrices, which in turn affected the drug release behavior. In general, surface modification of the BC matrices enhanced the drug release retardant properties in pre-modification drug loading. Surface modification was found to be effective for controlling the drug release properties of BC. Therefore, these modified BC matrices have the potential for applications in modified drug delivery systems.

Identification and Ablation of Dormant Conduction in Atrial Fibrillation Using Adenosine.

BACKGROUND: Ablation is used for treatment of atrial fibrillation (AF) but recurrence is common. Dormant conduction is hypothesized to be responsible for these recurrences, and the role of adenosine in identification and ablation of these pathways is controversial with conflicting results on AF recurrence. MATERIALS AND METHODS: We conducted a meta-analysis for studies evaluating AF ablation and adenosine use. Included in the meta-analysis were human studies that compared ablation using adenosine or adenosine triphosphate (ATP) and reported freedom from AF in patients beyond a minimum follow-up of 6 months. RESULTS: Our analysis suggests that the use of adenosine leads to a decrease in recurrence of AF compared to the cohort which did not utilize adenosine. Subgroup analysis showed no difference in the recurrence of AF with the modality used for ablation (cryoablation vs. radiofrequency ablation) or with the preparation of adenosine used (ATP vs. adenosine). There was a significant benefit in delayed administration of ATP over early administration. Pooling results of only randomized control trials did not show any significant difference in AF recurrence. CONCLUSIONS: Adenosine-guided identification and ablation of dormant pathways may lead to a decrease in recurrence of AF.

Risk of Ischemic Heart Disease in Patients With Sjögren's Syndrome.

BACKGROUND: Ischemic heart disease (IHD) has emerged as a major cause of morbidity and mortality in patients with autoimmune conditions such as systemic lupus erythematosus and rheumatoid arthritis, but the risk of IHD in Sjögren's syndrome (SjS) is unknown. To fill this knowledge gap, we estimated the prevalence and risk of IHD with SjS compared to controls from the general population using the Healthcare Cost and Utilization Project National Inpatient Sample 2011 database. MATERIALS AND METHODS: The Healthcare Cost and Utilization Project administrative longitudinal database contains encounter-level information on inpatient stays, emergency department visits and ambulatory surgery in all U.S. hospitals. We conducted a cross-sectional study among the inpatient population diagnosed with SjS and matched 1:4 with controls for age, sex and hospital region. Odds ratio for IHD was calculated as cases compared to controls. The contribution of various risk factors to IHD was also evaluated by logistic regression. RESULTS: Analysis demonstrated that 7,154 of 13,086 cases (54.7%) of SjS had IHD compared to 27,367 of 52,448 controls (52.2%). The adjusted odds ratio for IHD in those with SjS was 0.898 (95% CI: 0.844-0.955). Patients with SjS were significantly more likely to have hypertension, diabetes, apnea and lipid disorders. CONCLUSIONS: To our knowledge, this is the largest population-based study investigating the risk of IHD in patients with SjS. We found a modest, though statistically significant, decrease in the risk of IHD in SjS compared to controls.

Early coronary angiography in patients resuscitated from out of hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis.

OBJECTIVE: A meta-analysis of published studies was performed to determine the impact of performing early versus delayed or no coronary angiography in patients without ST-segment elevation myocardial infarction following out of hospital cardiac arrest. METHODS: A structured search was conducted using Medline, Embase and Ovid by two independent investigators using a variety of keywords. The primary outcome was short term (at discharge) and long term (at 6-14 months follow-up) mortality whereas the secondary end-point was good neurological outcome (defined as a Cerebral Performance Category Score of 1 or 2), at discharge and follow up. Random-effects model was utilized to pool the data, whilst publication bias was assessed using funnel plot. RESULTS: A total of 8 studies (7 observational studies and 1 randomized control trial) were identified and incorporated into the meta-analysis. The use of early angiography was associated with decreased short term (OR=0.46, 95% CI=0.36-0.56, P<0.001) and long term (OR=0.59, 95%CI=0.44-0.74, P<0.001) mortality. Early angiography was also shown to be associated with improved neurological outcomes on discharge (OR=2.00, 95% CI=1.50-2.49, P<0.001) as well as on follow-up (OR=1.48, 95% CI=1.06-1.90, P<0.001). CONCLUSION: The results of our meta-analysis support the use of early coronary angiography in out of hospital cardiac-arrest patients presenting without ST-segment elevation on the post-resuscitation electrocardiogram. However, given the low level of evidence of available studies, future guideline changes should be directed by the results of large-scale randomized clinical trials on the subject matter.

Characteristics of Highly Cited Articles in Interventional Cardiology.

Citation classics have been published in many fields of medicine; however, none have focused on interventional cardiology. The goal of this study was to identify the top 100 articles in the field of interventional cardiology and highlight their important trends and characteristics. The Scopus database was used by 2 independent reviewers to extract the top 100 articles using a variety of keywords. We found articles published between 1953 and 2012. Majority (n = 78) of the top 100 articles were published between 1996 and 2010, and the United States was affiliated with the highest number of articles in our list (n = 68). Over half (n = 54) the articles were funded. Private funding was correlated with higher citations (p = 0.036). A third (n = 33) of the papers had authors with conflicts of interest; however, conflict of interest had no effect on citations (p = 0.837). Majority (n = 57) of the articles studied coronary angioplasty and stenting; followed by coronary angiography (n = 14). Women were underrepresented, with only 11 female first authors in the top 100 papers, and only 1 female in the list of top authors who had 5 or more publications. In conclusion, the following features define the typical highly cited article in interventional cardiology-a clinical trial conducted in the United States, which studies angioplasty, and has been published relatively recently in a high-impact journal by a male first author.

Meta-analysis of Placebo-Controlled Randomized Controlled Trials on the Prevalence of Statin Intolerance.

The prevalence of intolerance varies widely. Stopping statin therapy is associated with worse outcomes in patients with cardiovascular disease. Despite extensive studies, the benefits and risks of statins continue to be debated by clinicians and the lay public. We searched the PubMed, Medline, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for all randomized controlled trials of statins compared with placebo. Studies were included if they had ≥1,000 participants, had patients who were followed up for ≥1 year, and reported rates of drug discontinuation. Studies were pooled as per the random effects model. A total of 22 studies (statins = 66,024, placebo = 63,656) met the inclusion criteria. The pooled analysis showed that, over a mean follow-up of 4.1 years, the rates of discontinuation were 13.3% (8,872 patients) for statin-treated patients and 13.9% (8,898 patients) for placebo-treated patients. The random effects model showed no significant difference between the placebo and statin arms (odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.93 to 1.06). The results were similar for both primary prevention (OR = 0.98, 95% CI = 0.92 to 1.05, p = 0.39) and secondary prevention (OR = 0.92, 95% CI = 0.83 to 1.05, p = 0.43) studies. The pooled analysis suggested that the rates of myopathy were also similar between the statins and placebos (OR = 1.2, 95% CI = 0.88 to 1.62, p = 0.25). In conclusion, this meta-analysis of >125,000 patients suggests that the rate of drug discontinuation and myopathy does not significantly differ between statin- and placebo-treated patients in randomized controlled trials. These findings are limited by the heterogeneity of results, the variable duration of follow-up, and the lower doses of statins compared with contemporary clinical practice.

The Use of Statins and Risk of Community-Acquired Pneumonia.

PURPOSE OF THE REVIEW: Community-acquired pneumonia (CAP) is still associated with a large burden and causes significant morbidity and mortality. Besides universal vaccination and antibiotic treatment, statins as adjunctive therapy may also have a beneficial role in the prevention and treatment of CAP. Our goal from this review is to discuss the epidemiology of CAP, and role of statins as adjunctive therapy in the development of CAP. RECENT FINDINGS: Statins are lipid-lowering medications characterized by their ability to control hypercholesterolemia in addition to other pleiotropic effects that could explain their role in the pathogenesis of CAP. While most observational studies have shown that statins reduce risk of pneumonia in the general population, patients with diabetes, and recently in patients with myocardial infarction, no randomized controlled trial (RCT) to date has been conducted to assess the efficacy of statins to prevent development of CAP. Given the paucity of robust randomized evidence to assess statin use and the development of CAP, and considering conflicting results of the observational studies, we are not in favor of initiation of statins for either the prevention or treatment of CAP.