Effect of Fixed-Bolus (5,000 Units) Unfractionated Heparin Before Primary Percutaneous Coronary Intervention on Activated Clotting Time, Time Flow, and All-Cause Mortality.

The American College of Cardiology Foundation /American Heart Association guidelines recommend a weight-based dose of unfractionated heparin (UFH) for primary percutaneous coronary intervention (PCI). However, it is convention to administer a fixed-bolus dose of 5,000 units of UFH. It is unclear if 5,000 units are sufficient to achieve a therapeutic first activated clotting time (ACT). We conducted a retrospective cohort study to determine the proportion of therapeutic first ACT in patients who received 5,000 units of UFH before primary PCI. We examined the association of therapeutic first ACT with clinical outcomes, including post-PCI Thombolysis in Myocardial Infarction (TIMI) grade flow, myocardial infarction, bleeding, and mortality. Among the 269 included patients, 74.7% were men, and 61.4% were overweight or obese. The mean first ACT was 243.4 (SD = 61.5) seconds. Most patients (56.1%) had an infratherapeutic first ACT, 21.9% had a therapeutic first ACT, and 21.9% had a supratherapeutic first ACT. Furthermore, 44.6% of patients who achieved the American College of Cardiology Foundation/American Heart Association target weight-based dosing had an infratherapeutic ACT. The proportion of patients with post-PCI TIMI grade flow 0 to 2 was 14.6% among those with a first ACT that was infratherapeutic versus 6.8% among those with a first ACT that was not infratherapeutic (relative risk 2.15, 95% CI 0.99 to 4.65). In conclusion, over half of patients with ST-elevation myocardial infarction administered 5,000 units of UFH have an infratherapeutic first ACT and the high rate of poor TIMI grade flow in patients with an infratherapeutic ACT is concerning.

Combination Therapies for Smoking Cessation: A Hierarchical Bayesian Meta-Analysis.

CONTEXT: Treatment guidelines recommend the use of combination therapies for smoking cessation, particularly behavioral therapy (BT) as an adjunct to pharmacotherapy. However, these guidelines rely on previous reviews with important limitations. This study's objective was to evaluate the efficacy of combination therapies compared with monotherapies, using the most rigorous data available. EVIDENCE ACQUISITION: A systematic review and meta-analysis of RCTs of pharmacotherapies, BTs, or both were conducted. The Cochrane Library, Embase, PsycINFO, and PubMed databases were systematically searched from inception to July 2015. Inclusion was restricted to RCTs reporting biochemically validated abstinence at 12 months. Direct and indirect comparisons were made in 2015 between therapies using hierarchical Bayesian models. EVIDENCE SYNTHESIS: The search identified 123 RCTs meeting inclusion criteria (60,774 participants), and data from 115 (57,851 participants) were meta-analyzed. Varenicline with BT increased abstinence more than other combinations of a pharmacotherapy with BT (varenicline versus bupropion: OR=1.56, 95% credible interval [CrI]=1.07, 2.34; varenicline versus nicotine patch: OR=1.65, 95% CrI=1.10, 2.51; varenicline versus short-acting nicotine-replacement therapies: OR=1.68, 95% CrI=1.15, 2.53). Adding BT to any pharmacotherapy compared with pharmacotherapy alone was inconclusive, owing to wide CrIs (OR=1.17, CrI=0.60, 2.12). Nicotine patch with short-acting nicotine-replacement therapy appears safe and increases abstinence versus nicotine-replacement monotherapy (OR=1.63, CrI=1.06, 3.03). Data are limited concerning other pharmacotherapy combinations and their safety and tolerability. CONCLUSIONS: Evidence suggests that combination therapy benefits may be less than previously thought. Combined with BT, varenicline increases abstinence more than other pharmacotherapy with BT combinations.

Meta-Analysis of the Long-Term Effect of Routine Aspiration Thrombectomy in Patients Undergoing Primary Percutaneous Coronary Intervention.

American College of Cardiology Foundation/American Heart Association guidelines no longer recommend the use of routine aspiration thrombectomy during primary percutaneous coronary intervention (PCI). This is based on evidence from recent randomized controlled trials (RCTs) that suggests that the long-term benefits of aspiration thrombectomy were previously overestimated. We conducted a systematic review and meta-analysis of RCTs to examine the effect of routine aspiration thrombectomy during primary PCI versus primary PCI alone on markers of reperfusion immediately after PCI and on clinical outcomes at ≥6 months. We systematically searched Medline, EMBASE, and the Cochrane Library of Clinical trials for RCTs published in English or French with follow-up ≥6 months. Data were pooled using random-effects models. Eighteen publications (containing data from 14 RCTs, n = 20,285) met our inclusion criteria. Aspiration thrombectomy was associated with higher rates of ST-segment resolution (relative risk [RR] 1.22, 95% CI 1.07 to 1.40) and myocardial blush grade 3 (RR 1.30, 95% CI 1.01 to 1.67) and a reduced risk of no reflow immediately after PCI (RR 0.63, 95% CI 0.40 to 0.98). However, thrombectomy was not associated with our primary outcome of all-cause mortality at longest available follow-up (RR 0.92, 95% CI 0.81 to 1.04). Similar results were obtained for myocardial infarction and target vessel/lesion revascularization. Thrombectomy also increased the risk of stroke (RR 1.59, 95% CI 1.07 to 2.35). In conclusion, routine aspiration thrombectomy during primary PCI has some short-term clinical benefits but does not improve outcomes ≥6 months and increases the risk of stroke.

Systematic Review of the Mediterranean Diet for Long-Term Weight Loss.

BACKGROUND: Although the long-term health benefits of the Mediterranean diet are well established, its efficacy for weight loss at ≥12 months in overweight or obese individuals is unclear. We therefore conducted a systematic review of randomized controlled trials (RCTs) to determine the effect of the Mediterranean diet on weight loss and cardiovascular risk factor levels after ≥12 months. METHODS: We systematically searched MEDLINE, EMBASE, and the Cochrane Library of Clinical Trials for RCTs published in English or French and with follow-up ≥12 months that examined the effect of the Mediterranean diet on weight loss and cardiovascular risk factor levels in overweight or obese individuals trying to lose weight. RESULTS: Five RCTs (n = 998) met our inclusion criteria. Trials compared the Mediterranean diet to a low-fat diet (4 treatment arms), a low-carbohydrate diet (2 treatment arms), and the American Diabetes Association diet (1 treatment arm). The Mediterranean diet resulted in greater weight loss than the low-fat diet at ≥12 months (range of mean values: -4.1 to -10.1 kg vs 2.9 to -5.0 kg), but produced similar weight loss as other comparator diets (range of mean values: -4.1 to -10.1 kg vs -4.7 to -7.7 kg). Moreover, the Mediterranean diet was generally similar to comparator diets at improving other cardiovascular risk factor levels, including blood pressure and lipid levels. CONCLUSION: Our findings suggest that the Mediterranean diet results in similar weight loss and cardiovascular risk factor level reduction as comparator diets in overweight or obese individuals trying to lose weight.