A meta-analysis of optimal medical therapy with or without percutaneous coronary intervention in patients with stable coronary artery disease.

BACKGROUND: Whether percutaneous coronary intervention (PCI) improves clinical outcomes in patients with chronic angina and stable coronary artery disease (CAD) has been a continuing area of investigation for more than two decades. The recently reported results of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches, the largest prospective trial of optimal medical therapy (OMT) with or without myocardial revascularization, provides a unique opportunity to determine whether there is an incremental benefit of revascularization in stable CAD patients. METHODS: Scientific databases and websites were searched to find randomized clinical trials (RCTs). Pooled risk ratios were calculated using the random-effects model. RESULTS: Data from 10 RCTs comprising 12 125 patients showed that PCI, when added to OMT, were not associated with lower all-cause mortality (risk ratios, 0.96; 95% CI, 0.87-1.08), cardiovascular mortality (risk ratios, 0.91; 95% CI, 0.79-1.05) or myocardial infarction (MI) (risk ratios, 0.90; 95% CI, 0.78-1.04) as compared with OMT alone. However, OMT+PCI was associated with improved anginal symptoms and a lower risk for revascularization (risk ratios, 0.52; 95% CI, 0.37-0.75). CONCLUSIONS: In patient with chronic stable CAD (without left main disease or reduced ejection fraction), PCI in addition to OMT did not improve mortality or MI compared to OMT alone. However, this strategy is associated with a lower rate of revascularization and improved anginal symptoms.

A Meta-analysis of Clinical Trials Evaluating the Impact of Bivalirudin-based Anticoagulation for Primary Percutaneous Coronary on Long-Term Mortality.

ABSTRACT: Bivalirudin and heparin are the principal anticoagulants used during primary percutaneous coronary intervention (PCI) for patients experiencing ST-elevation myocardial infarctions. Based on previous meta-analyses, bivalirudin improves 30-day mortality rates compared with heparin, especially when vascular access is predominantly femoral. However, no meta-analysis has yet reported whether this mortality benefit with bivalirudin persists beyond 30 days. Scientific databases and websites were searched to find randomized controlled trials, and risk ratios (RRs) were calculated using random effect models. Data from 4 trials were analyzed. Compared with heparin ± glycoprotein IIb/IIIa inhibitors, bivalirudin decreased all-cause mortality [RR, 0.81; 95% confidence interval (CI), 0.69-0.94; P = 0.008], cardiac mortality (RR, 0.72; 95% CI, 0.60-0.88; P = 0.001), and net adverse clinical events (RR, 0.83; 95% CI, 0.72-0.97; P = 0.016) at 1 year. In conclusion, a bivalirudin-based anticoagulation strategy during primary percutaneous coronary intervention significantly decreases the 1-year risks for all-cause mortality, cardiac mortality, and net adverse clinical events compared with heparin ± glycoprotein IIb/IIIa inhibitor.

Meta-Analysis of Optimal Revascularization Strategy for Patients With ST-Segment Elevation Myocardial Infarction and Multi-Vessel Coronary Artery Disease.

Several clinical trials have shown that complete revascularization (CR) lowers the risks of revascularization and nonfatal myocardial infarction (MI) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease compared with infarct-related artery-only revascularization (IRA-OR). However, individual trials have been underpowered for hard outcomes such as cardiovascular (CV) mortality. Therefore, we conducted an updated meta-analysis representing the largest sample size to date inclusive of contemporary studies comparing CR versus IRA-OR. Pooled risk ratios (RRs) were calculated using random effects model. Data from 11 RCTs involving 7,343 patients showed that compared with IRA-OR, CR was associated with lower CV mortality (RR 0.75; 95% confidence interval [CI] 0.57 to 0.99; p = 0.04), MI (RR 0.70; 95% CI 0.53 to 0.93), and recurrent revascularization (RR 0.38; 95% CI 0.27 to 0.54), but similar all-cause mortality (RR 0.85; 95% CI 0.70 to 1.05). In conclusion, in patients with STEMI and multivessel coronary artery disease, compared with IRA-OR, CR was associated with lower risk for CV mortality, MI, and recurrent revascularization, suggesting that CR should be the standard of care for STEMI patients.

Parasympathetic effects on heart rate recovery after exercise.

BACKGROUND: Exercise and its recovery period are associated with increased risk of death relative to sedentary periods. They are also accompanied by dynamic changes in autonomic tone. Little information is available regarding parasympathetic effects during high-intensity exercise and recovery. METHODS: Ten normal subjects (five women; age 33 +/- 2 years) underwent exercise testing on a bicycle ergometer. On day 1, subjects exercised to maximum tolerated workload using a graded protocol with 5 minutes at maximal workload (peak heart rate achieved 174.7 +/- 5.4 bpm). On day 2, subjects performed the identical exercise protocol as on day 1; 1 minute into the maximum exercise stage, atropine (0.04 mg/kg) was administered. Heart rate was recorded every minute during exercise, and an electrocardiogram was recorded every minute in recovery for 10 minutes. The parasympathetic effect on heart rate was defined by the difference in heart rate with and without atropine. RESULTS: The parasympathetic effect during maximal exercise was 3.4 to 6 bpm (p < .05). During recovery, a large parasympathetic effect on heart rate was noted by 1 minute (22.8 bpm; p < .0002), increased until 4 minutes, and then remained stable until 10 minutes. Despite faster heart rates with parasympathetic blockade, the P-R interval was shorter (p < .002), consistent with a significant parasympathetic effect on the atrioventricular node in recovery. Evaluation of the Q-T-R-R relationship on the 2 days demonstrated significant changes in both the slope (p < .0001) and the intercept (p < .0001), consistent with a modification of ventricular repolarization by parasympathetic tone in recovery. CONCLUSION: These data indicate that in normal subjects, parasympathetic effects persist during high-intensity exercise and are prominent in the early phases of recovery. These parasympathetic effects may play an important role in prevention of sudden cardiac death during these periods of increased risk.