Extracorporeal Membrane Oxygenation Pathway for Management of Refractory Cardiac Arrest: A Retrospective Study from A National Center of Extracorporeal Cardiopulmonary Resuscitation.

BACKGROUND: Cardiac arrest remains a critical condition with high mortality and catastrophic neurological impact. Extracorporeal cardiopulmonary resuscitation (ECPR) has been introduced as an adjunct in cardiopulmonary resuscitation modalities. However, survival with good neurological outcomes remains a major concern. This study aims to explore our early experience with ECPR and identify the factors associated with survival in patients presenting with refractory cardiac arrest. METHODS: A retrospective cohort study analyzing six-year data from a tertiary center, the country reference for ECPR. SETTING: A national center of ECPR. PARTICIPANTS: Adult patients who experienced witnessed refractory cardiopulmonary arrest and were supported by ECPR. INTERVENTIONS: ECPR for eligible patients as per local service protocol. RESULTS: Data from 87 patients were analyzed; of this cohort, 62/87 patients presented with in-hospital cardiac arrest (IHCA), and 25/87 presented with out-of-hospital cardiac arrest (OHCA). Overall survival to decannulation and hospital discharge rates were 26.4% and 25.3%, respectively. Among survivors (n=22), 19 presented with IHCA (30.6%), whilst only 3 survivors presented with OHCA (12%). A total of 15/87 (17%) patients were alive at 6-month follow-up. All survivors had good neurological function assessed as Cerebral Performance Category 1 or 2. Multivariate logistic regression to predict survival to hospital discharge showed that IHCA was the only independent predictor (Odds Ratio 5.8, p =0.042), however, this positive association disappeared after adjusting for the first left ventricular ejection fraction after resuscitation. CONCLUSION: In this study, the use of ECPR for IHCA was associated with a higher survival to discharge compared to OHCA. This study demonstrated a comparable survival rate to other established centers, particularly for IHCA. Neurological outcomes were comparable in both IHCA and OHCA survivors. However, large multicenter studies are warranted for better under-standing and improving the outcomes.

Effectiveness of a structured pharmacist-delivered intervention for patients post-acute coronary syndromes on all-cause hospitalizations and cardiac-related hospital readmissions: a prospective quasi-experimental study.

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity in Qatar and globally. AIM: The primary objective of the study was to evaluate the effectiveness of a structured clinical pharmacist-delivered intervention on all-cause hospitalizations and cardiac-related readmissions in patients with ACS. METHOD: A prospective quasi-experimental study was conducted at Heart Hospital in Qatar. Discharged ACS patients were allocated to one of three study arms: (1) an intervention group (received a structured clinical pharmacist-delivered medication reconciliation and counselling at discharge, and two follow-up sessions at 4 weeks and 8 weeks post-discharge), (2) a usual care group (received the general usual care at discharge by clinical pharmacists) or, (3) a control group (discharged during weekends or after clinical pharmacists' working hours). Follow-up sessions for the intervention group were designed to re-educate and counsel patients about their medications, remind them about the importance of medication adherence, and answer any questions they may have. At the hospital, patients were allocated into one of the three groups based on intrinsic and natural allocation procedures. Recruitment of patients took place between March 2016 and December 2017. Data were analyzed based on intention-to-treat principles. RESULTS: Three hundred seventy-three patients were enrolled in the study (intervention = 111, usual care = 120, control = 142). Unadjusted results showed that the odds of 6-month all-cause hospitalizations were significantly higher among the usual care (OR 2.034; 95% CI: 1.103-3.748, p = 0.023) and the control arms (OR 2.704; 95% CI: 1.456-5.022, p = 0.002) when compared to the intervention arm. Similarly, patients in the usual care arm (OR 2.304; 95% CI: 1.122-4.730, p = 0.023) and the control arm (OR 3.678; 95% CI: 1.802-7.506, p ≤ 0.001) had greater likelihood of cardiac-related readmissions at 6 months. After adjustment, these reductions were only significant for cardiac-related readmissions between control and intervention groups (OR 2.428; 95% CI: 1.116-5.282, p = 0.025). CONCLUSION: This study demonstrated the impact of a structured intervention by clinical pharmacists on cardiac-related readmissions at 6 months post-discharge in patients post-ACS. The impact of the intervention on all-cause hospitalization was not significant after adjustment for potential confounders. Large cost-effective studies are required to determine the sustained impact of structured clinical pharmacist-provided interventions in ACS setting. TRIAL REGISTRATION: Clinical Trials: NCT02648243 Registration date: January 7, 2016.

Effectiveness of Sacubitril/Valsartan in Heart Failure with Reduced Ejection Fraction Using Real-World Data: An Updated Systematic Review and Meta-Analysis.

We conducted a systematic review and meta-analysis to assess all-cause mortality and heart failure (HF) hospitalization with sacubitril/valsartan (S/V) compared to standard HF therapy in patients with HF with reduced ejection fraction (HFrEF) using real-world data. We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed and Google Scholar for the observational studies published in English exploring the clinical outcomes of S/V use in HFrEF till March 14, 2022. Two independent reviewers assessed the quality and risk of bias of the included studies. A random-effect model was used to combine data. The outcomes assessed were all-cause mortality and HF hospitalization associated with S/V use in comparison to standard HF therapy. A total of 9 observational studies comparing S/V to Angiotensin-converting enzyme inhibitors (ACE-I)/Angiotensin II receptor blockers (ARB) in HFrEF were included in the systematic review, with more than 32000 patients included in the final analysis. Overall, S/V use was associated with a significant reduction in all-cause mortality (Risk Ratio [RR] = 0.70, 95% CI 0.53-0.93, I2 = 83%) and HF hospitalization (RR = 0.62; 95% CI, 0.48-0.80, I2= 94%). Similar to the landmark controlled evidence, real-world data of S/V use in HFrEF demonstrated a significant reduction in all-cause mortality and HF hospitalization.

A Comparative Study of High-intensity Rosuvastatin Versus Atorvastatin Therapy Post-acute Coronary Syndrome Using Real-world Data.

A high-intensity statin is recommended for the secondary prevention of cardiovascular diseases (CVD). However, real-world evidence of the effectiveness of rosuvastatin following acute coronary syndrome (ACS) is scarce. This retrospective cohort study included patients diagnosed with ACS to compare between the 2 high-intensity statin therapies (rosuvastatin vs atorvastatin) in terms of a primary composite outcome of CVD-associated death, non-fatal ACS, and non-fatal stroke at 1 month and 12 months post discharge. The primary effectiveness outcome did not differ between the 2 groups at 1 month (1.3% vs 1%; aHR = 1.64, 95% CI 0.55-4.94, P= 0.379) and at 12 months (4.8% vs 3.5%; aHR = 1.48, 95% CI 0.82-2.67, P= 0.199). Similarly, the 2 groups had comparable safety outcomes. In conclusion, the use of high-intensity rosuvastatin compared to high-intensity atorvastatin therapy in patients with ACS had resulted in comparable cardiovascular effectiveness and safety outcomes.

Impact of COVID-19 pandemic on liver, liver diseases, and liver transplantation programs in intensive care units.

Emerging worldwide data have been suggesting that coronavirus disease 2019 (COVID-19) pandemic consequences are not limited to the respiratory and cardiovascular systems but encompass adverse gastrointestinal manifestations including acute liver injury as well. Severe cases of liver injury associated with higher fatality rates were observed in critically ill patients with COVID-19. Intensive care units (ICU) have been the center of disposition of severe cases of COVID-19. This review discusses the pathogenesis of acute liver injury in ICU patients with COVID-19, and analyzes its prevalence, consequences, possible drug-induced liver injury, and the impact of the pandemic on liver diseases and transplantation programs.

PCSK9 Monoclonal Antibodies: An Overview.

PCSK9 monoclonal antibodies are novel lipid-lowering therapy that have been extensively studied in patients with hypercholesterolemia either as monotherapy or as an add-on to other LLTs. PCSK9 monoclonal antibodies have significantly reduced the low-density lipoprotein cholesterol (LDL-C) plasma level resulting in a better LDL-C goal attainment. The commercially available PCSK9 monoclonal antibodies, alirocumab and evolocumab, have demonstrated reductions in major adverse cardiovascular events such as myocardial infarction, stroke, unstable angina, and the need for coronary revascularization but not mortality. PCSK9 monoclonal antibodies have demonstrated a favorable safety profile. The most reported side effects are mild injection site with no causal relationship proven between the inhibition of PCSK9 and neurocognitive or glycemic adverse events. In this overview, the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of primary and familial hypercholesterolemia will be discussed.

Efficacy and safety of PCSK9 monoclonal antibodies: an evidence-based review and update.

OBJECTIVE: Treatment of dyslipidemia lowers cardiovascular (CV) risk. Although statin use is a cornerstone therapy, many patients are not achieving their risk-specific low-density lipoprotein cholesterol (LDL-C) goals. The proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies have been extensively studied as lipid-lowering therapy (LLT). Herein, we present an updated evidence-based review of the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of familial and non-familial hypercholesterolemia. METHODS: PubMed database was searched to review Phase III studies on PCSK9 monoclonal antibodies. Then, the US National Institutes of Health Registry and the WHO International Clinical Trial Registry Platform were searched to identify and present the ongoing research. RESULTS: PCSK9 monoclonal antibodies were investigated for the treatment of dyslipidemia, as a single therapeutic agent or as an add-on therapy to the traditional LLT. They proved effective and safe in the treatment of familial and non-familial hypercholesterolemia, and in the prevention of adverse CV events. CONCLUSIONS: The use of PCSK9 monoclonal antibodies in the treatment of dyslipidemia is currently recommended to achieve risk-specific LDL-C goal to reduce adverse CV events. Future results of the ongoing research might expand their clinical generalizability to broader patient populations.

Molecular and clinical roles of incretin-based drugs in patients with heart failure.

Glucagon-like peptide-1 (GLP-1) agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors produce some beneficial and deleterious effects in diabetic patients not mediated by their glycemic lowering effects, and there is a need for better understanding of the molecular basis of these effects. They possess antioxidant and anti-inflammatory effects with some direct vasodilatory action (animal and human trial data) that may indirectly influence heart failure (HF). Unlike GLP-1R agonists, signaling for HF adverse effects was observed with two DPP-4 inhibitors, saxagliptin and alogliptin. Accordingly, these drugs should be used with caution in heart failure patients.