Ankur Sethi

Complete versus culprit only revascularization in acute ST elevation myocardial infarction: A meta‐analysis

Background: Current guidelines recommend against the revascularization of noninfarct related artery (complete revascularization [CR]) in patients with ST elevation myocardial infarction (STEMI) and no hemodynamic compromise, though level of evidence is C. Aim: Our aim was to examine the available evidence to determine any advantage of CR over culprit only revascularization (COR). Methods: We systematically searched medline using key words—“culprit coronary revascularization,” “complete revascularization myocardial infarction,” and “multivessel STEMI” for studies reporting outcomes after COR versus CR during primary procedure or index hospitalization published in English language and indexed before February 2010. A random effect or fixed effect meta‐analysis, as applicable, was performed using RevMan 5 (Cochrane Center, Denmark). Results: Nine eligible nonrandomized studies amounting to 4,530 patients in CR and 27,323 patients in COR group were included. In addition, two small randomized trials were reviewed and included in secondary analysis. Majority of patients were hemodynamically stable. Major adverse cardiovascular events (Odds ratio [OR] = 0.95, 95% CI 0.47–1.90) and long term mortality (OR = 1.10, 95% CI 0.76–1.59) were similar. The marginal increased odds of in‐hospital mortality was derived from a single study with no difference found after sensitivity and cumulative analysis (OR = 1.21 95% CI 0.85–1.73). Conclusion: Current analysis of heterogeneous studies did not reveal any benefit of CR over COR in patients with STEMI. However, also provide no conclusive evidence of increased in hospital mortality after CR. A randomized trial is needed to confirm these findings and recognize any subgroup which might benefit from CR.

Glycoprotein IIb/IIIa inhibitors with or without thienopyridine pretreatment improve outcomes after primary percutaneous coronary intervention in high-risk patients with ST elevation myocardial infarction--a meta-regression of randomized controlled trials.

Recent studies have casted a doubt on usefulness of routine glycoprotein IIb/IIIA inhibitors (GPI) in patients, pretreated with aspirin and clopidogrel, undergoing primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI).

Prevention of Recurrent Atrial Fibrillation With Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers: A Systematic Review and Meta-Analysis of Randomized Trials:

Background: Controversy persists regarding the efficacy of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in the prevention of recurrent atrial fibrillation (AF). We performed a meta-analysis of randomized controlled trials (RCTs), not designed a priori to test this hypothesis, to explore whether ACEs and ARBs reduce recurrent AF. Methods: We performed a systematic literature search for RCTs using ACEIs or ARBs and providing data on the outcome of recurrent AF. Statistical heterogeneity across the trials was tested using the Cochran Q statistic and I2 was computed to quantify heterogeneity. A 2-sided α error of less than .05 was considered statistically significant (P < .05). Results: The analysis was based on 8 RCTs including 2323 patients. The Mantel-Haenszel random-effect model was used to calculate relative risk (RR) for studies using ACEIs or ARBs, and for studies using ARBs. The fixed-effect model was used to calculate RR for studies using ACEIs. Meta-analysis of the studies revealed that ACEIs or ARBs significantly reduced the incidence of recurrent AF (RR, 0.611; 95% CI, 0.441-0.847; P = .003). The RR for recurrent AF was 0.643 (95% CI, 0.439-0.941; P = .023) for studies using ARBs and 0.54 (95% CI, 0.377-0.80; P = .002) for studies using ACEIs. Conclusion: In this meta-analysis of RCTs not designed a priori to test the hypothesis, ACEs and ARBs were associated with a significant reduction in recurrent AF. Large-scale randomized trials designed a priori to test the hypothesis are necessary to complete the totality of evidence.

Tirofiban Use With Clopidogrel and Aspirin Decreases Adverse Cardiovascular Events After Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction: A Meta-analysis of Randomized Trials

Current guidelines deemed usefulness of routine early glycoprotein IIb/IIIa inhibitor (GPI) administration in ST-elevation myocardial infarction (STEMI) before primary percutaneous coronary intervention (PCI) with dual antiplatelet therapy as uncertain. We aimed to examine the current evidence for the use of tirofiban, a nonpeptide glycoprotein IIb/IIIa inhibitor, in STEMI patients treated with dual antiplatelet therapy. We performed systematic searches of MEDLINE, EMBASE, and CENTRAL databases for randomized controlled trials (RCTs) of tirofiban use in STEMI patients treated with aspirin and clopidogrel which reported clinical and/or angiographic outcomes after primary PCI. Data were combined using random effect and fixed effect models for heterogeneous and homogeneous outcomes respectively using Review Manager 5 (The Nordic Cochrane Centre, The Cochrane Collaboration, 2008). Six randomized controlled trials were eligible for the inclusion; involving 708 patients in tirofiban group and 721 control subjects. Routine tirofiban use decreased the major adverse cardiovascular events (odds ratio [OR] 0.50; 95% confidence interval [CI], 0.26-0.94). Corrected thrombolysis in myocardial infarction (TIMI) frame count was also reduced with tirofiban (mean difference -8.48 [95% CI, -12.62 to -4.34]). There were no significant differences in the rates of postprocedure TIMI flow grade 3 and TIMI myocardial perfusion/blush grade 3, major bleeding by TIMI criteria, or mortality in the 2 groups. Current analysis of available studies suggests that routine and early tirofiban use before primary PCI may decrease the major cardiovascular events in STEMI patients treated with aspirin and clopidogrel without any significant increase in major bleeding. An adequately powered randomized trial is urgently needed to confirm the above findings and estimate the effect size.

Zotarolimus-eluting stent versus sirolimus-eluting and paclitaxel-eluting stents for percutaneous coronary intervention: a meta-analysis of randomized trials.

BACKGROUNDnThe zotarolimus-eluting stent (ZES) is a new drug-eluting stent that delivers zotarolimus, a synthetic analogue of sirolimus, through a biocompatible phosphorylcholine polymer coating. ZES has shown promising results compared with bare-metal stents, but its safety and efficacy against sirolimus-eluting (SES) and paclitaxel-eluting (PES) stents is yet to be established.nnnAIMSnWe aimed to summarize current evidence from randomized trials comparing ZES with SES and PES.nnnMETHODSnWe searched the Medline, Embase and CENTRAL databases for randomized studies comparing ZES with SES and PES for percutaneous coronary intervention. Relevant clinical and angiographic outcomes were extracted and combined using random and fixed-effect models for heterogeneous and homogenous outcomes, respectively.nnnRESULTSnSeven randomized trials met the inclusion criteria: ZES group, n=3787; SES group, n=2606; PES group, n=1966. Compared with SES, ZES was associated with significantly higher odds of clinically driven target vessel revascularization (odds ratio [OR] 2.36, 95% confidence interval [CI] 1.78-3.14) and target lesion revascularization (OR 2.46, 95% CI 1.36-4.46). Compared with SES, ZES had higher in-stent restenosis (OR 6.13, 95% CI 3.96-9.50), late lumen loss in-stent (mean difference [MD] 0.39 mm, 95% CI 0.34-0.44) and late lumen loss in-segment (MD 0.18 mm, 95% CI 0.15-0.21). ZES was associated with higher in-stent late lumen loss than PES (MD 0.18 mm, 95% CI 0.07-0.28). There were no differences in mortality, reinfarction or stent thrombosis with ZES compared with SES and PES.nnnCONCLUSIONnZES is not superior to PES and is inferior to SES in terms of angiographic outcomes and clinically driven revascularization.

OMEGA-3 FATTY ACIDS IN PREVENTION OF POST-CARDIAC SURGERY ATRIAL FIBRILLATION: A META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Previous randomized studies have reported conflicting results on the efficacy of omega-3 fatty acids (PUFA) in preventing atrial fibrillation (AF) post cardiac surgery. Therefore, a meta-analysis of the role of PUFA in the prevention of atrial fibrillation in post-cardiac surgery patients was

Expanding giant right coronary artery aneurysm: an acute need for new management strategies.

Angiography use has become increasingly common worldwide. Coronary artery aneurysm may be an incidental finding during angiography. Occasionally it might be symptomatic or may become symptomatic over the course of time. Rupture of aneurysm may lead to disastrous complications. Here we present a case in which aneurysm was asymptomatic but surgical intervention was done because of rapid increase in the size of aneurysm. This is to drive home the point that timely surgical intervention is instrumental in preventing complications associated with possible rupture of the aneurysm.

ANTIPLATELET AND ANTICOAGULANT USE FOR ACUTE MYOCARDIAL INFARCTION IN EMERGENCY DEPARTMENT: “A CASE FOR QUALITY IMPROVEMENT” – AN ANALYSIS FROM NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY 2002-2010

Quality improvement registries have shown high antiplatelet (ap) and anticoagulant (ac) use within 24 hours of hospitalization for acute myocardial infarction (AMI). But, unbiased national estimate of utilization of these therapies in emergency department (ED) is not known.nnWe analyzed data from

Rebuttal: Culprit only versus complete revascularization in st elevation myocardial infarction

We read the letter to the editor regarding our metaanalysis with great interest. It is an articulate representation of prevailing concerns in cardiology community regarding complete revascularization in patients with ST elevation myocardial infarction (STEMI). The writer correctly points out the variability in definitions used across the studies to describe the complete revascularization procedure. In particular, studies have defined the complete revascularization to encompass the revascularization of nonculprit vessels performed during the index procedure, index hospitalization or as staged procedure postindex hospitalization [1,2]. To deal with this ambiguity, we restricted our meta-analysis to studies, which performed complete revascularization during index hospitalization. The writer has raised several other important issues.

IMPACT OF PRE-OPERATIVE CLOPIDOGREL USE IN PATIENTS WITH NON-ST SEGMENT ELEVATION ACUTE CORONARY SYNDROME REQUIRING CORONARY ARTERY BYPASS GRAFTING: A META-ANALYSIS

Methods: We performed a systematic search for studies comparing death, re-operation for bleeding and packed red blood cell (PRBC) transfusion in patients exposed (Group A) versus not exposed (Group B) to clopidogrel within 5 days of CABG in the setting of NSTE-ACS. Five trials with 7212 patients were included. Relative risks (RR) and 95% confidence intervals (CI) were computed. A two-sided alpha error of < 0.05 was considered as statistically significant (p<0.05).