Temporary-Permanent Pacemakers in the Management of Conduction Abnormalities in Patients Undergoing Transcatheter Aortic Valve Replacement.

Background: Injury to the cardiac conduction system requiring a permanent pacemaker (PPM) implantation is a known adverse outcome of transcatheter aortic valve replacement (TAVR). Temporary-permanent pacemakers (TPPM) have been used as a bridge to PPM implantation in patients with systemic infection; however, there are only a few reports of its routine use in patients undergoing TAVR. This study aimed to assess the utility of routine use of TPPM in patients undergoing TAVR with a high risk of needing a PPM or those who develop high-grade conduction abnormalities during/after TAVR. Methods: Between April 2015 and December 2021, 978 patients underwent TAVR at our institution, of whom 111 patients had TPPM placed before or during/after TAVR during the study period. In total, 89 patients were included in the final analysis. Results: The median age was 78 years (IQR, 71-84 years); 52 (58.4%) patients with preexisting native conduction disease were considered high risk for advanced heart block and had TPPM placed before TAVR. In addition, 37 (41.6%) patients had TPPM placed during/after TAVR. Of the 89 patients who received TPPM, 51 (57.3%) were treated with a balloon-expandable valve and 38 (42.7%) with a self-expandable valve. Of the patients who underwent TPPM placement, only 49 (55.1%) required a PPM, and TPPM was removed in 40 (44.9%) patients. TPPM was in place for a median of 6 days (IQR, 2-11 days). Only 1 of the 89 patients (1.1%) who received a TPPM had lead dislodgment. No other complications were noted. Median length of stay was 3 days (IQR, 2-4 days). Conclusions: In patients with high-risk baseline conduction abnormalities before TAVR and those who develop new high-grade conduction abnormalities during/after TAVR, TPPM provides a feasible and safe method for pacing that could allow early ambulation, facilitate early discharge, and prevent unnecessary PPM implantations in some patients.

Meta-Analysis of Prophylactic Renal Replacement Therapy after Cardiac Catheterization in Patients with Chronic Kidney Disease.

BACKGROUND: The benefits of prophylactic renal replacement therapy after cardiac catheterization in patients with chronic kidney disease remain unclear. The aim of this study is to confirm the benefit of prophylactic renal replacement therapy after cardiac catheterization. METHODS: We systematically searched for studies published from inception to December 2022 examining the benefits of prophylactic renal replacement therapy after cardiac catheterization in MEDLINE and EMBASE. Data analysis was performed according to the PRISMA statement using the Mantel-Haenszel method. RESULTS: Five studies met the inclusion criteria, which comprised of 532 chronic kidney disease patients who underwent coronary angiography (268 had prophylactic renal replacement therapy and 264 did not have prophylactic renal replacement therapy). The pooled analysis revealed a non-significant decreased risk of 1-year mortality in chronic kidney disease patients who underwent coronary angiography and prophylactic renal replacement therapy compared to those who did not have prophylactic renal replacement therapy (RR = 0.59; P =.18; CI: 0.28-1.2795, I2 = 60.4%). The risk of hemodialysis during hospitalization and renal replacement therapy requirement in 1 year in chronic kidney disease patients who underwent coronary angiography and prophylactic renal replacement therapy were lower than in those who did not have prophylactic renal replacement therapy (RR = 0.13; P =.001; CI: 0.04-0.43, I2 = 9.1% and RR = 0.29; P =.015; CI: 0.11-0.78, I2 = 49.9%, respectively). The sensitivity analysis demonstrated that the overall findings remained consistent and did not significantly alter. CONCLUSIONS: Prophylactic renal replacement therapy did not seem to lower 1-year mortality among chronic kidney disease patients who underwent coronary angiography. However, prophylactic renal replacement therapy appeared to reduce the risk of hemodialysis during hospitalization and renal replacement therapy requirement in 1 year.

Predicting arrhythmic event score in Brugada syndrome: Worldwide pooled analysis with internal and external validation.

BACKGROUND: Brugada syndrome is an inherited arrhythmic disease associated with major arrhythmic events (MAE). Risk predictive scores were previously developed with various performances. OBJECTIVE: The purpose of this study was to create a novel score-Predicting Arrhythmic evenT (PAT)-with internal and external validation. METHODS: A systematic review was performed to identify risk factors for MAE. The odds ratios (ORs) of each factor were pooled across studies. The PAT scoring scheme was developed based on pooled ORs. The PAT score was internally validated with published 105 Asian patients (follow-up 8.0 ± 4.1 [SD] years) and externally validated with unpublished 164 multiracial patients (82.3% White, 14.6% Asian, 3.2% Black; mean follow-up 8.0 ± 6.9 years) with Brugada syndrome. Performances were assessed and compared with previous scores using receiver operating characteristic curve (ROC) analysis. RESULTS: Sixty-seven studies published between 2002 and 2022 from 26 countries (7358 patients) were included. Pooled ORs were estimated, indicating that 15 of 23 risk factors were significant. The PAT score was then developed accordingly. The PAT score had significantly better discrimination (ROC 0.9671) than the BRUGADA-RISK score (ROC 0.7210; P = .006), Shanghai Score System (ROC 0.7079; P = .003), and Sieira et al score (ROC 0.8174; P = .026) in an external validation cohort. PAT score ≥ 10 predicted the first MAE with 95.5% sensitivity and 89.1% specificity (ROC 0.9460) and the recurrent MAE (ROC 0.7061) with 15.4% sensitivity and 93.3% specificity. CONCLUSION: The PAT score was shown to be useful in predicting MAE for primary prevention in patients with Brugada syndrome.

Type of syncope and outcome in Brugada syndrome: A systematic review and meta-analysis.

Introduction: Brugada syndrome is an inherited arrhythmic disease associated with major arrhythmic events (MAE). The importance of primary prevention of sudden cardiac death (SCD) in Brugada syndrome is well recognized; however, ventricular arrhythmia risk stratification remains challenging and controversial. We aimed to assess the association of type of syncope with MAE via systematic review and meta-analysis. Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2021. Included studies were cohort (prospective or retrospective) studies that reported the types of syncope (cardiac, unexplained, vasovagal, and undifferentiated) and MAE. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate the odds ratio (OR) and 95% confidence intervals (CIs). Results: Seventeen studies from 2005 to 2019 were included in this meta-analysis involving 4355 Brugada syndrome patients. Overall, syncope was significantly associated with an increased risk of MAE in Brugada syndrome (OR = 3.90, 95% CI: 2.22-6.85, p < .001, I 2 = 76.0%). By syncope type, cardiac (OR = 4.48, 95% CI: 2.87-7.01, p < .001, I 2 = 0.0%) and unexplained (OR = 4.71, 95% CI: 1.34-16.57, p = .016, I 2 = 37.3%) syncope was significantly associated with increased risk of MAE in Brugada syndrome. Vasovagal (OR = 2.90, 95% CI: 0.09-98.45, p = .554, I 2 = 70.9%) and undifferentiated syncope (OR = 2.01, 95% CI: 1.00-4.03, p = .050, I 2 = 64.6%, respectively) were not. Conclusion: Our study demonstrated that cardiac and unexplained syncope was associated with MAE risk in Brugada syndrome populations but not in vasovagal syncope and undifferentiated syncope. Unexplained syncope is associated with a similar increased risk of MAE compared to cardiac syncope.

Characteristics and outcomes of patients with sepsis who had cortisol level measurements or received hydrocortisone during their intensive care unit management: A retrospective single center study.

Objectives: The current guidelines for managing patients with sepsis include the early cultures, administration of antibiotics, and fluid resuscitation. Several clinical trials have tried to determine whether or not the administration of corticosteroids improves outcomes in these patients. This study analyzed the characteristics of a large group of critically ill patients who either had cortisol levels drawn during their intensive care unit management or had hydrocortisone administered during their management. Methods: A list of patients who had cortisol levels measured or who had hydrocortisone administered empirically for the treatment of sepsis was identified by the medical record department at University Medical Center in Lubbock, Texas. The primary outcome was in-hospital mortality. Secondary outcomes included the need for mechanical ventilation, the need for renal replacement therapy, the need for vasopressors, length of stay, and the development of nosocomial infections. Results: This study included 351 patients, including 194 women (55.3%). The mean age was 62.9 ± 16.1 years. The mean admission SOFA score was 9.3 ± 3.63, the mean APACHE 2 score was 18.15 ± 7.7, and the mean lactic acid level was 3.8 ± 4.0 mmol/L. One hundred sixty-two patients required intubation, 262 required vasopressors, 215 developed acute kidney injury, and 319 had cortisol levels measured. The mean length of stay was 11.5 ± 13.7 days; the mortality rate was 32.2%. Multiple variable analysis demonstrated that higher cortisol levels were associated with increased mortality (44.1% if cortisol ⩾20 µg/dL versus 17.5% if cortisol <20 µg/dL). One hundred forty-five patients received corticosteroids, and multivariable analysis demonstrated that these patients had increased mortality (40.0% versus 26.7%). Conclusion: In this study, higher cortisol levels were associated with increased mortality. The administration of hydrocortisone was associated with increased mortality possibly reflecting the use of this medication in patients who had a higher likelihood of poor outcomes.

Surgical versus catheter ablation in atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Atrial fibrillation (AF) is the most common cardiac arrhythmia with a high stroke and mortality rate. The video-assisted thoracoscopic radiofrequency pulmonary vein ablation is a treatment option for patients who fail catheter ablation. Randomized data comparing surgical versus catheter ablation are limited. We performed a meta-analysis of randomized control trials to explore the outcome efficacy between surgical and catheter radiofrequency pulmonary vein ablation in patients with AF. METHODS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2020. Included studies were published randomized control trials that compared video-assisted thoracoscopic and catheter radiofrequency pulmonary vein ablation. Data from each study were combined using the fixed-effects, generic inverse variance method of DerSimonian, and Laird to calculate odds ratios and 95% confidence intervals. RESULTS: Six studies from November 2013 to 2020 were included in this meta-analysis involving 511 AF patients (79% paroxysmal) with 263 catheter ablation (mean age 56 ± 3 years) and 248 surgical ablations (mean age 52 ± 4 years). Catheter ablation was associated with increased atrial arrhythmias recurrence when compared to surgical ablation (pooled relative risk = 1.85, 95% confidence interval: 1.44-2.39, p < .001, I2 = 0.0%) but associated with less total major adverse events (pooled relative risk = 0.29, 95% confidence interval: 0.16-0.53, p < .001, I2 = 0.0%). In subgroup analysis, catheter ablation was associated with increased AF recurrence in refractory paroxysmal AF when compared to surgical ablation (pooled relative risk = 2.47, 95% confidence interval: 1.31-4.65, p = .005, I2 = 0.0%) but not in persistent AF (relative risk = 1.09, 95% confidence interval: 0.60-2.0, p = .773). CONCLUSION: Catheter ablation was associated with higher atrial arrhythmia recurrence when compared with surgical ablation. However, our study suggests that the benefit of surgical ablation in patients with persistent AF is unclear. More studies and alternative ablation strategies investigation in persistent AF are warranted.

Percutaneous closure of patent foramen ovale for treatment of hypoxemia: A case series and physiology review.

Intracardiac right-to-left shunt (RTLS) mediated hypoxemia is a rare complication of patent foramen ovale (PFO). The process may be potentiated by reversal of the usual trans-atrial pressure gradient, or from alteration of intracardiac geometry such that venous flow is preferentially directed toward the PFO. We describe a series of four patients who presented with hypoxemia, detailing the diagnostic evaluation which led to the ascertainment of intracardiac RTLS across PFO as the culprit pathology. All underwent successful percutaneous closure with rapid resolution of hypoxemia. Particular attention is given to the underlying anatomic and physiologic derangements facilitating the intracardiac RTLS.

Antiplatelet therapy associated with lower prevalence of advanced liver fibrosis in non-alcoholic fatty liver disease: A systematic review and meta-analysis.

Despite the growing disease burden of non-alcoholic fatty liver disease (NAFLD), approved medical treatments to improve or prevent liver fibrosis are effective only in a small number of patients. Recent studies have found the new use of antiplatelet agents for antifibrotic benefits in NAFLD, but human studies are still limited. The goal of this meta-analysis was to combine the findings of existing relevant studies to investigate the effects of antiplatelet therapy in reducing or preventing advanced liver fibrosis in patients with NAFLD. We conducted a systematic literature search in PubMed, EMBASE, and Web of Science databases from inception to January 2021 to identify all original studies that investigated the use of antiplatelet agents in patients with NAFLD. We used the National Institutes of Health's quality assessment tool for observational cohort and cross-sectional studies to assess study quality and risk of bias. The primary outcome was the prevalence of advanced liver fibrosis stage 3-4. Data from each study was combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled odds ratio (OR) and 95% confidence intervals (CIs). Of the 2,498 studies identified, 4 studies involving 2,593 patients with NAFLD were included in this study (949 antiplatelet agent users and 1,644 non-antiplatelet agent users). The use of aspirin and/or P2Y12 receptor inhibitors was associated with a lower pooled OR of advanced liver fibrosis in patients with NAFLD (pooled OR = 0.66; 95% CI: 0.53-0.81, I2 = 0.0%; p < 0.001). This study focuses on the outcome of advanced liver fibrosis in patients with NAFLD. Our study is limited by the small number of studies that were included. Preliminary evidence from this meta-analysis suggests a protective association between antiplatelet therapy and the prevalence of advanced liver fibrosis in patients with NAFLD. Our findings support future research into repositioning an antiplatelet agent as a novel NAFLD treatment.

Pregnancy Counseling in a Young Woman With Left Ventricular Non-Compaction.

Left ventricular noncompaction (LVNC) is an uncommon form of cardiomyopathy. Its prevalence in adults is 1:5000. In the differential diagnosis of congestive heart failure, it is rarely the etiology. The etiology of LVNC may be genetic or acquired. There are not guidelines regarding pregnancy planning or outcome in women with this disease. In this presentation, we bring the issue of genetics and pregnancy counseling in women with left ventricular noncompaction.

Admission hyperglycemia is associated with reperfusion failure in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: a systematic review and meta-analysis.

BACKGROUND: Admission hyperglycemia (AH) is a common finding in patients with acute coronary syndrome and has been reported to be associated with increased morbidity and mortality. Prior studies suggest that AH could be associated with reperfusion failure. We conducted a systematic review and meta-analysis to explore an association between AH and risk of reperfusion failure in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). METHODS: Two investigators searched the databases of MEDLINE and EMBASE from inception to February 2021. Study eligibility was independently determined by two investigators and needed to demonstrate association of AH and rate of reperfusion failure, or sufficient raw data to calculate the effect size. Participants were classified into two groups corresponding to their level of admission hyperglycemia. Group 1 was defined as an AH of ≥120-150 mg/dl, and group 2 as ≥150-200 mg/dl. Data from each study were combined using the random-effects model, the generic inverse-variance method of Der Simonian and Laird. The heterogeneity of effect size was quantified using the I2 statistic. A sensitivity analysis was performed by omitting one study at a time. Publication bias was assessed using a funnel plot and the Egger's test. All data analyses were performed using STATA SE version 14.2. RESULTS: A total of ten studies from 2008 to 2019 met eligibility criteria and were included in the final analysis. We found that AH is associated with increased risk of reperfusion failure in both group 1 (pooled OR=1.78, 95% CI: 1.35-2.33, I2=63.2%, P<0.001) and group 2 (pooled OR=1.44, 95% CI: 1.14-1.82, I2=57.1%, P<0.001). Sensitivity analysis showed that none of the results were significantly altered after removing one study at a time. In subgroup analysis of non-diabetic patients, we found that AH is also associated with increased risk of reperfusion failure in both group 1 (pooled OR=1.81, 95% CI: 1.29-2.54, P<0.001) and group 2 (pooled OR=1.61, 95% CI: 1.17-2.21, P<0.001). We did not perform a funnel plot or Egger's test as the number of available outcomes was insufficient to reject the assumption of funnel plot asymmetry. CONCLUSIONS: Our systematic review and meta-analysis demonstrated that AH is associated with increased risk of reperfusion failure in STEMI patients undergoing pPCI, in the non-diabetic population.

Does the Age of Sudden Cardiac Death in Family Members Matter in Brugada Syndrome?

Background Brugada syndrome is an inherited cardiac channelopathy associated with major arrhythmic events (MAEs). The presence of a positive family history of sudden cardiac death (SCD) as a risk predictor of MAE remains controversial. We aimed to examine the association between family history of SCD and MAEs stratified by age of SCD with a systematic review and meta-analysis. Methods and Results We searched the databases of MEDLINE and EMBASE from January 1992 to January 2020. Data from each study were combined using the random-effects model. Fitted metaregression was performed to evaluate the association between the age of SCD in families and the risk of MAE. Twenty-two studies from 2004 to 2019 were included in this meta-analysis involving 3386 patients with Brugada syndrome. The overall family history of SCD was not associated with increased risk of MAE in Brugada syndrome (pooled odds ratio [OR], 1.11; 95% CI, 0.82-1.51; P=0.489, I2=45.0%). However, a history of SCD in family members of age younger than 40 years of age did increase the risk of MAE by ≈2-fold (pooled OR, 2.03; 95% CI, 1.11-3.73; P=0.022, I2=0.0%). When stratified by the age of cut point at 50, 45, 40, and 35 years old, a history of SCD in younger family member was significantly associated with a higher risk of MAE (pooled OR, 0.49, 1.30, 1.51, and 2.97, respectively; P=0.046). Conclusions A history of SCD among family members of age younger than 40 years was associated with a higher risk of MAE.

The effects of marital status on outcome of heart failure population: a systematic review and meta-analysis.

BACKGROUND: Traditional risk factors for worse outcome in heart failure (HF) are well-established. However, there are still many unknown risk factors for worse outcome in this population. Several studies have shown that unmarried status is associated with an increased risk of rehospitalization and mortality in HF patients. However, there is no systematic review or meta-analysis to confirm this association. We performed a systematic review and meta-analysis to explore the effect of marital status on outcome regarding mortality and rehospitalization in HF population. METHODS: We searched the databases of MEDLINE and EMBASE from inception to July 2019. Included studies were published cohort studies or randomised controlled trials reporting rates of mortality and/or rehospitalization in HF patients, married and unmarried. Data from each study were combined using the random-effects model. RESULTS: Ten studies were included in our meta-analysis. We found that unmarried status is associated with increased risk of mortality (pooled OR = 1.52, 95%CI = 1.30-1.78, p < .001), increased risk of rehospitalization (pooled OR = 1.80, 95%CI = 1.18-2.74, p = .007), and increased risk of combined endpoint of mortality and rehospitalization (pooled OR = 1.72, 95%CI = 1.36-2.17, p < .001). CONCLUSIONS: Our meta-analysis demonstrated that being unmarried, divorced, and widowed is associated with a worse outcome in HF population regarding mortality and rehospitalization rate.

Angiotensin II antagonists and gastrointestinal bleeding in left ventricular assist devices: A systematic review and meta-analysis.

Gastrointestinal bleeding (GIB) especially from arteriovenous malformations (AVM) remains one of the devastating complications following continuous-flow left ventricular device (CF-LVAD) implantation. Blockade of angiotensin II pathway using angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) was reported to mitigate the risk of GIB and AVM-related GIB by suppressing angiogenesis. We performed a systematic review and meta-analysis to evaluate the association between ACEI/ARB treatment and GIB in CF-LVAD population. Comprehensive literature search was performed through December 2019. We included studies reporting risk of GIB and/or AVM-related GIB events in LVAD patients who received ACEI/ARB with those who did not. Data from each study were combined using the random-effects to calculate odd ratios and 95% confidence intervals. Three retrospective cohort studies were included in this meta-analysis involving 619 LVADs patients (467 patients receiving ACEI/ARB). The use of ACEI/ARB was statistically associated with decreased incidence of overall GIB (pooled OR 0.35, 95% CI 0.22-0.56, I2 = 0.0%, p < 0.001). There was a non-significant trend toward lower risk for AVM-related GIB in patients who received ACEI/ARB (pooled OR 0.46, 95% CI 0.19-1.07, I2 = 51%, p = 0.07). Larger studies with specific definitions of ACEI/ARB use and GIB are warranted to accurately determine the potential non-hemodynamic benefits of ACEI/ARB in CF-LVAD patients.

Renal sympathetic denervation in addition to pulmonary vein isolation reduces the recurrence rate of atrial fibrillation: an updated meta-analysis of randomized control trials.

BACKGROUND/PURPOSE: Atrial fibrillation (AF) is the most common arrhythmia worldwide. The sympathetic nervous system plays an important role in initiation and maintenance of AF. Recent studies have shown that renal sympathetic denervation (RSD) reduced AF recurrences after conventional pulmonary vein isolation (PVI). Studies that have evaluated the role of RSD as an adjuvant to PVI have included different patient populations, ablation strategies, and follow-up approaches. We performed a meta-analysis to assess the potential incremental impact of RSD to PVI. METHODS: We searched the databases of MEDLINE and EMBASE from inception to January 2020. Included studies were randomized controlled trials (RCTs) that compared the recurrence rates of AF in patients who underwent PVI and RSD versus PVI alone. Data from each study were combined using the random effects model to calculate odds ratios (OR) and 95% confidence intervals (CIs). RESULTS: Three RCTs consisted of four different studies during 2014-2020 involving 451 AF patients (223 patients underwent PVI alone and 228 patients underwent PVI with RSD) were included in the meta-analysis. Compared with PVI alone, the PVI with RSD group had a significantly lower risk of AF recurrence (pooled OR = 0.63, 95%CI 0.50-0.80, p < 0.001, I2 = 0.0%). There was no publication bias observed in funnel plot as well as no small-study effect observed in Egger's test. CONCLUSIONS: Our systematic review and meta-analysis demonstrated a significant reduction of AF recurrence in select hypertensive patients who underwent RSD in addition to PVI compared with PVI alone. Larger studies are needed to validate the benefits of this approach in other AF populations and across different ablation strategies.

Association between depression and increased risk of readmission in patients with heart failure: a systematic review and meta-analysis.

INTRODUCTION: Heart failure (HF) is one of the world leading causes of admission and readmission. Recent studies have shown that the presence of depression is associated with hospital readmission in patients after an index admission for heart failure (HF). However, there is disagreement between published studies regarding this finding. We performed a systematic review and meta-analysis to evaluate the effect of depression on readmission rates in HF patients. EVIDENCE ACQUISITION: We searched the databases of MEDLINE and EMBASE from inception to March 2020. Included studies were published study evaluating readmission rate of HF patients, with and without depression. Data from each study were combined using a random-effects model, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. EVIDENCE SYNTHESIS: Ten studies were included in the meta-analysis with a total of 53,165 patients (6194 patients with depression). The presence of depression was associated with an increased risk of readmission in patients with HF (pooled HR=1.54, 95% CI: 1.22-1.94, P<0.001, I2=55.4%). In a subgroup analysis, depression was associated with an increased risk of readmission in patients with HF in both short-term (≤90 days) follow-up (pooled HR=1.75, 95% CI: 1.07-2.85, P=0.025, I2=76.0%) and long-term (>90 days) follow-up (pooled HR=1.58, 95% CI: 1.32-1.90, P<0.001, I2=0.0%). CONCLUSIONS: Our meta-analysis demonstrated that depression is associated with an increased risk of hospital readmission in patients with HF.

Association of frailty with all-cause mortality and bleeding among elderly patients with acute myocardial infarction: a systematic review and meta-analysis.

BACKGROUND: Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly. It is related to unfavorable outcomes in various cardiovascular conditions. We conducted a systematic review and meta-analysis of the association of frailty with all-cause mortality and bleeding after acute myocardial infarction (AMI) in the elderly. METHODS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2019. The studies that reported mortality and bleeding in AMI patients who were evaluated and classified by frailty status were included. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate hazard ratio (HR), and 95% confidence interval (CI). RESULTS: Twenty-one studies from 2011 to 2019 were included in this meta-analysis involving 143,301 subjects (mean age 75.33-year-old, 60.0% male). Frailty status was evaluated using different methods such as Fried Frailty Index. Frailty was statistically associated with increased early mortality in nine studies (pooled HR = 2.07, 95% CI: 1.67-2.56, P < 0.001, I 2 = 41.2%) and late mortality in 11 studies (pooled HR = 2.30, 95% CI: 1.70-3.11, P < 0.001, I 2 = 65.8%). Moreover, frailty was also statistically associated with higher bleeding in 7 studies (pooled HR = 1.34, 95% CI: 1.12-1.59, P < 0.001, I 2 = 4.7%). CONCLUSION: Frailty is strongly and independently associated with bleeding, early and late mortality in elderly with AMI. Frailty assessment should be considered as an additional risk factor and used to guide toward personalized treatment strategies.

The utility of drug challenge testing in Brugada syndrome: A systematic review and meta-analysis.

INTRODUCTION: Brugada syndrome (BrS) is associated with ventricular arrhythmia leading to sudden cardiac death. Risk stratification is challenging, as major arrhythmic events (MAEs) are rare. We assessed the utility of drug challenge testing in BrS by a systematic review and meta-analysis. METHODS AND RESULTS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2019. Included studies compared the incidence of MAE between spontaneous and drug challenge-induced Type 1. Mixed-effects Poisson regression was used to calculate the incidence rate ratio (IRR). Eighteen studies from 2006 to 2018 were included (4099 patients, mean follow-up: 4.5 years). Pooled annual incidences of MAE in spontaneous, drug challenge induced (regardless of symptoms), asymptomatic drug challenge induced, and symptomatic drug challenge-induced Type 1 were 23.8 (95% confidence interval [CI]: 19.8-27.8), 6.5 (95% CI: 3.9-9.1), 2.1 (95% CI: -0.3 to 4.4), and 19.6 (95% CI: 9.9-29.3) per 1000 person-years, respectively. The incidence of MAE between symptomatic drug challenge induced and asymptomatic spontaneous Type 1 was not statistically different (IRR = 1.0; 95% CI: 0.6-1.7). CONCLUSIONS: The incidence of MAE in drug challenge-induced Type 1 in asymptomatic patients is low. The incidence of MAE between symptomatic drug challenge induced and asymptomatic spontaneous Type 1 was similar.