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5.
Coron Artery Dis ; 33(2): 91-97, 2022 03 01.
Article in English | MEDLINE | ID: mdl-33878073

ABSTRACT

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.


Subject(s)
Coronary Artery Disease/therapy , Percutaneous Coronary Intervention/standards , Cardiovascular Agents/adverse effects , Cardiovascular Agents/pharmacology , Coronary Artery Disease/complications , Humans , Percutaneous Coronary Intervention/methods , Treatment Outcome
6.
J Cardiovasc Pharmacol ; 78(1): e40-e44, 2021 07 01.
Article in English | MEDLINE | ID: mdl-33929388

ABSTRACT

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.


Subject(s)
Antithrombins/therapeutic use , Peptide Fragments/therapeutic use , Percutaneous Coronary Intervention/mortality , ST Elevation Myocardial Infarction/therapy , Antithrombins/adverse effects , Evidence-Based Medicine , Female , Hemorrhage/chemically induced , Hirudins/adverse effects , Humans , Male , Middle Aged , Peptide Fragments/adverse effects , Percutaneous Coronary Intervention/adverse effects , Randomized Controlled Trials as Topic , Recombinant Proteins/adverse effects , Recombinant Proteins/therapeutic use , Risk Assessment , Risk Factors , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/mortality , Time Factors , Treatment Outcome
11.
Am J Cardiol ; 134: 69-73, 2020 11 01.
Article in English | MEDLINE | ID: mdl-32892993

ABSTRACT

Statin therapy is the gold standard for hypercholesterolemia. However, a significant number of patients cannot achieve their target low-density lipoprotein (LDL) levels despite a maximal dose of statin therapy, and some cannot tolerate statins at all. Approval of proprotein convertase subtilisin/kexin type 9 inhibitors has been revolutionary for those patients. However, the need for frequent injections limits patient compliance with their use. Recently, a twice-yearly injection of inclisiran, a small interfering RNA, has been shown to inhibit hepatic synthesis of proprotein convertase subtilisin/kexin type 9. However, patient randomized clinical trial has been underpowered for clinical end points, necessitating a meta-analysis of those trials. The weighted mean difference was used to describe continuous variables, and pooled risk ratios, calculated using a random effects model, were used to describe discrete variables. Data from 3 randomized clinical trials comprising 3,660 patients showed that inclisiran decreased LDL cholesterol levels by 51% (95% Confidence Interval, 48 to 53%; p < 0.001) compared with placebo. It was associated with a 24% lower major adverse cardiovascular events rate (risk ratios = 0.76; 95% Confidence Interval, 0.61 to 0.92). It also significantly decreased total cholesterol by 37%, apolipoprotein B by 41%, and non high-density lipoprotein (HDL) cholesterol by 45% (all p < 0.001). No differences were found in adverse events, abnormalities in liver function tests, or creatine kinase levels between the treatment strategies. However, a mild injection site reaction occurred more frequently in the inclisiran group. In conclusions, in patients with hypercholesterolemia, inclisiran decreased LDL level by 51% without significant adverse effects. Additionally, it was associated with a lower major adverse cardiovascular event rate.


Subject(s)
Anticholesteremic Agents/therapeutic use , Hypercholesterolemia/drug therapy , Injection Site Reaction/epidemiology , RNA, Small Interfering/therapeutic use , Aged , Alanine Transaminase/metabolism , Alkaline Phosphatase/metabolism , Apolipoproteins B/metabolism , Aspartate Aminotransferases/metabolism , Bilirubin/metabolism , Cardiovascular Diseases/mortality , Cholesterol/metabolism , Cholesterol, HDL/metabolism , Cholesterol, LDL/metabolism , Creatine Kinase/metabolism , Drug Therapy, Combination , Ezetimibe/therapeutic use , Female , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Hypercholesterolemia/metabolism , Male , Middle Aged , Myocardial Infarction/epidemiology , Randomized Controlled Trials as Topic , Stroke/epidemiology
13.
Am J Cardiol ; 129: 19-24, 2020 08 15.
Article in English | MEDLINE | ID: mdl-32540166

ABSTRACT

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.


Subject(s)
Cardiovascular Diseases/mortality , Coronary Artery Disease/surgery , Coronary Stenosis/surgery , Myocardial Infarction/epidemiology , Percutaneous Coronary Intervention/methods , ST Elevation Myocardial Infarction/surgery , Humans , Mortality , Recurrence
14.
Quant Imaging Med Surg ; 10(4): 891-894, 2020 Apr.
Article in English | MEDLINE | ID: mdl-32355657
17.
Cardiovasc Revasc Med ; 21(6): 792-796, 2020 06.
Article in English | MEDLINE | ID: mdl-31672535

ABSTRACT

BACKGROUND: Aspirin (ASA) monotherapy is the current standard of care after coronary artery bypass grafting (CABG) to prevent saphenous vein graft (SVG) failure. Several small, randomized clinical trials (RCTs) have suggested that dual antiplatelet therapy (DAPT) may be more effective at preventing SVG failure than ASA alone; however, it is unclear whether some P2Y12 inhibitors are more effective than others for the prevention of SVG failure. METHODS: Scientific databases and websites were searched to find RCTs. Both traditional pairwise meta-analysis using random-effect model and network meta-analysis using mixed-treatment comparison models were performed to compare the efficacy of various anti-platelet strategies for the prevention of SVG failure. RESULTS: Nine RCTs, which included a total of 1677 patients, were analyzed. Compared to ASA alone, DAPT decreased the risk of graft failure by 37% (RR: 0.63, 95% CI: 0.47-0.86; p = 0.003). In the moderator analysis, the decreased risk of graft failure with DAPT was not significantly different in the ASA + clopidogrel group than in the ASA + ticagrelor group (P-interaction = 0.17). The results of the network meta-analysis were consistent with those from pairwise analyses. The risk of major bleeding was not statistically significantly different between DAPT and ASA alone (RR: 1.35, 95% CI: 0.62-2.94; p = 0.45). CONCLUSION: In post-CABG patients, DAPT seems to be more effective at preventing graft failure than ASA alone. This strategy does not seem to significantly increase major bleeding risk. Clopidogrel- and ticagrelor-based DAPT seem to be equally effective for this indication.


Subject(s)
Aspirin/administration & dosage , Coronary Artery Bypass , Coronary Artery Disease/surgery , Dual Anti-Platelet Therapy , Graft Occlusion, Vascular/prevention & control , Platelet Aggregation Inhibitors/administration & dosage , Purinergic P2Y Receptor Antagonists/administration & dosage , Saphenous Vein/transplantation , Aged , Aspirin/adverse effects , Bayes Theorem , Coronary Artery Bypass/adverse effects , Coronary Artery Disease/diagnostic imaging , Dual Anti-Platelet Therapy/adverse effects , Female , Graft Occlusion, Vascular/etiology , Hemorrhage/chemically induced , Humans , Male , Middle Aged , Network Meta-Analysis , Platelet Aggregation Inhibitors/adverse effects , Purinergic P2Y Receptor Antagonists/adverse effects , Randomized Controlled Trials as Topic , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome
20.
Am J Med ; 132(11): 1295-1304.e3, 2019 11.
Article in English | MEDLINE | ID: mdl-31153866

ABSTRACT

BACKGROUND: The role of aspirin for primary prevention of cardiovascular diseases remains controversial, particularly in the context of contemporary aggressive preventive strategies. METHODS: Relevant randomized clinical trials were included, and risk ratios (RRs) were calculated using random-effects models. Additional moderator analyses were performed to compare the pooled treatment effects from recent trials (those reported after the guidelines of the National Cholesterol Education Program Third Adult Treatment Panel were published in 2001; thus, conducted on the background of contemporary preventive strategies) to the results of older trials. RESULTS: Data from 14 randomized controlled trials involving 164,751 patients were included. Aspirin use decreased myocardial infarction risk by 16% compared with placebo (RR 0.84; 95% confidence interval [CI], 0.75-0.94); however, in the moderator analyses, aspirin was not associated with a decreased risk of myocardial infarction in recent trials, but was in older trials (P-interaction = .02). Overall, aspirin use significantly increased the occurrence of major bleeding (RR 1.49; 95% CI, 1.32-1.69) and hemorrhagic stroke (RR 1.25; 95% CI, 1.01-1.54). In moderator analyses, the risk of major bleeding (P-interaction = .12) or hemorrhagic stroke (P-interaction = .44) with aspirin was not significantly different between the older and new trials. Differences between aspirin and placebo in the risks for all-cause stroke, cardiac death, and all-cause mortality were not found. CONCLUSIONS: In the context of contemporary primary prevention guidelines, the effect of aspirin on myocardial infarction risk was significantly attenuated, whereas its major bleeding and hemorrhagic stroke complications were retained. Therefore, in contemporary practice, routine use of aspirin for the primary prevention of cardiovascular events may have a net harmful effect.


Subject(s)
Aspirin/therapeutic use , Cardiovascular Diseases/prevention & control , Platelet Aggregation Inhibitors/therapeutic use , Primary Prevention , Aspirin/adverse effects , Hemorrhage/chemically induced , Humans , Intracranial Hemorrhages/chemically induced , Platelet Aggregation Inhibitors/adverse effects , Randomized Controlled Trials as Topic
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