Bhavi Pandya

Safety and efficacy of second-generation versus first-generation cryoballoons for treatment of atrial fibrillation: a meta-analysis of current evidence

BackgroundThe newer second-generation cryoballoons (CB-2 or Arc-Adv-CB) have been shown to achieve significantly lower temperature and faster pulmonary vein isolation (PVI) time in comparison with first-generation cryoballoons (CB-1 or Arc-CB). To test the premise that second-generation cryoballoons can improve clinical outcomes in comparison to first-generation cryoballoons in terms of safety and efficacy, we pooled data for systemic review and meta-analyses from all available literature comparing their clinical performance.MethodsThe Cochrane Library, PubMed, Google Scholar, and studies presented at various meetings were searched for any published literature comparing safety and efficacy of the second-generation cryoballoons (Arctic Front Advance cryoballoons) with first-generation cryoballoons (Arctic Front Cryoballoons). A total of ten published studies, with 2310 patients, were included in this meta-analysis with 957 patients in second-generation cryoballoon group and 1237 patients in first-generation cryoballoon group.ResultsThe pooled analysis showed significant superiority of second-generation cryoballoons in terms of less procedure time, less fluoroscopic time, and fewer incidences of arrhythmia recurrences compared to first-generation cryoballoons at the cost of higher incidence of persistent and transient phrenic nerve palsy. The differences in the rate of pericardial effusion and incidence of access site complications were not statistically significant.ConclusionsSecond-generation cryoballoons are associated with a shorter procedure time and fluoroscopy time, along with lower arrhythmia recurrence rates, reflecting higher procedure efficacy when compared to first-generation cryoballoons. However, they are also associated with a higher incidence of transient and persistent phrenic nerve palsies with a non-significant difference in rates of access site complications and pericardial effusion.

Biodegradable polymer stents vs second generation drug eluting stents: A meta-analysis and systematic review of randomized controlled trials

AIM To evaluate the premise, that biodegradable polymer drug eluting stents (BD-DES) could improve clinical outcomes compared to second generation permanent polymer drug eluting stents (PP-DES), we pooled the data from all the available randomized control trials (RCT) comparing the clinical performance of both these stents. METHODS A systematic literature search of PubMed, Cochrane, Google scholar databases, EMBASE, MEDLINE and SCOPUS was performed during time period of January 2001 to April 2015 for RCT and comparing safety and efficacy of BD-DES vs second generation PP-DES. The primary outcomes of interest were definite stent thrombosis, target lesion revascularization, myocardial infarction, cardiac deaths and total deaths during the study period. RESULTS A total of 11 RCTs with a total of 12644 patients were included in the meta-analysis, with 6598 patients in BD-DES vs 6046 patients in second generation PP-DES. The mean follow up period was 16 mo. Pooled analysis showed non-inferiority of BD-DES, comparing events of stent thrombosis (OR = 1.42, 95%CI: 0.79-2.52, P = 0.24), target lesion revascularization (OR = 0.99, 95%CI: 0.84-1.17, P = 0.92), myocardial infarction (OR = 1.06, 95%CI: 0.86-1.29, P = 0.92), cardiac deaths (OR = 1.07, 95%CI 0.82-1.41, P = 0.94) and total deaths (OR = 0.96, 95%CI: 0.80-1.17, P = 0.71). CONCLUSION BD-DES, when compared to second generation PP-DES, showed no significant advantage and the outcomes were comparable between both the groups.

Contrast media use in patients with chronic kidney disease undergoing coronary angiography: A systematic review and meta-analysis of randomized trials

BACKGROUND Patients with chronic kidney disease (CKD) undergoing coronary angiography (CA), adequate hydration and minimizing volume of contrast media (CM) are class 1b recommendations for preventing contrast induced nephropathy (CIN). Current data are insufficient to justify specific recommendations about isoosmolar vs. low-osmolar contrast media by the ACCF/AHA/SCAI guidelines. METHODS Randomized trials comparing IOCM to LOCM in CKD stage 3 and above patients undergoing CA, and reporting incidence of CIN (defined by a rise in creatinine of 25% from baseline) were included in the analysis. The secondary outcome of the study was the incidence of serum creatinine increase by >1mg/dl. RESULTS A total of 2839 patients were included in 10 trials, in which 1430 patients received IOCM and 1393 received LOCM. When compared to LOCM, IOCM was not associated with significant benefit in preventing CIN (OR=0.72, [CI: 0.50-1.04], P=0.08, I2=59%). Subgroup analysis revealed non-significant difference in incidence of CIN based on baseline use of N-acetylcystine (NAC), diabetes status, ejection fraction, and whether percutaneous coronary intervention vs coronary angiography alone was performed. The difference between IOCM and LOCM was further attenuated when restricted to studies with larger sample size (>250 patients) (OR=0.93; [CI: 0.66-1.30]) or when compared with non-ionic LOCM (OR=0.79, [CI: 0.52-1.21]). CONCLUSION In patients with CKD stage 3 and above undergoing coronary angiography, use of IOCM showed overall non-significant difference in incidence of CIN compared to LOCM. The difference was further attenuated when IOCM was compared with non-ionic LOCM.

Probiotics—To Use, or Not to Use? An Updated Meta-analysis

Prophylactic probiotics can influence gut colonization by pathogenic bacteria. Their influence on necrotizing enterocolitis (NEC), mortality and sepsis is controversial. A recent large randomized controlled trial by Costeloe et al showed no effect of Bifidobacterium breve on NEC, mortality, and culture-proven sepsis, which is contrary to large meta-analyses on the topic. Probiotics have not been shown to significantly reduce culture-proven sepsis in the Cochrane review. Our goal is to provide an updated meta-analysis, with the inclusion of findings of Costeloe et al, on the influence of probiotic supplementation and neonatal outcomes.

Anti-arrhythmic medications increase non-cardiac mortality - A meta-analysis of randomized control trials.

Anti‐arrhythmic medications (AAMs) are known to increase cardiac mortality significantly due to their pro‐arrhythmic effects. However, the effect of AAMs on non‐cardiac mortality has not been evaluated.

Acute Myocarditis in a Patient Using Testosterone Diagnosed by Cardiac MRI

Bhavi Pandya1*, Adarsh Vennepureddy1, Neeraj Shah1, Deepak Asti2, Nikhil Nalluri1 and Ruben Kandov2 1Department of Internal Medicine, Staten Island University Hospital, NY, USA 2Department of Cardiology, Staten Island University Hospital, NY, USA *Corresponding author: Bhavi Pandya, MBBS, Department of Internal medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA, Tel: +1 9099643904; E-mail: dr.bhavipandya@gmail.com

Treatment of Venous Thromboembolism in Elite Athletes: A Suggested Approach to Individualized Anticoagulation

Abstract Venous thromboembolism (VTE) is a leading cause of morbidity with potentially detrimental career consequences in elite athletes. Their unique predisposing factors entail a higher‐than‐expected VTE incidence. Anticoagulation treatment is challenging, especially among those athletes wishing to resume their competitive activities. The authors review the current VTE treatment guidelines from the perspective of treating elite athletes. They then provide an expert opinion individualized treatment approach based on the pharmacokinetic properties of direct oral anticoagulants that permits tailoring the drugs timing to the athletes competitive endeavors. They also present low‐molecular‐weight heparin as an alternative. The proposed risk management approach allows mitigation against VTE recurrence, reducing the chance of major bleeding, and honoring the athletes self‐determination to resume their career while accepting the risks involved. A shared decision making with the athlete and his/her team along with the presence of adequate resources are key components. Ultimately, the authors hope this work will serve as a stepping stone to validated VTE treatment regimens that consider the particularities of elite athletes.

Periprocedural Outcomes of Direct Oral Anticoagulants vs. Warfarin in Non-Valvular Atrial Fibrillation: A Meta-analysis of Phase III Trials

Background: Direct oral anticoagulants (DOACs) are surpassing warfarin as the anticoagulant of choice for stroke prevention in nonvalvular atrial fibrillation. DOAC outcomes in elective periprocedural settings have not been well elucidated and remain a source of concern for clinicians. The aim of this meta-analysis was to evaluate the periprocedural safety and efficacy of DOACs versus warfarin in patients with nonvalvular atrial fibrillation. Methods: We reviewed the literature for data from phase III randomized controlled trials comparing DOACs with warfarin in the periprocedural period among patients with nonvalvular atrial fibrillation. Substudies from 4 trials (RE-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy], ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibitor Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation], ARISTOTLE [Apixaban for the Prevention of Stroke in Subjects With Atrial Fibrillation], and ENGAGE-AF [Effective Anticoagulation With Factor xA Next Generation in Atrial Fibrillation]) were included in the meta-analysis. DOACs as a group and warfarin were compared in terms of the 30-day pooled risk for stroke/systemic embolism, major bleeding, and death, according to whether the study drug was interrupted or not periprocedurally. The overall relative risk (RR) was estimated with a random-effects model. The I2 test was used to assess heterogeneity in RR among the studies. Results: In the uninterrupted anticoagulant strategy, there were no differences in the rates of stroke/systemic embolism (pooled risk, 0.6% [29 events/4519 procedures] versus 1.1% [31/2971]; RR, 0.70; 95% confidence interval [CI], 0.41–1.18) and death (1.4% versus 1.8%; RR, 0.77; 95% CI, 0.53–1.12) between DOACs and warfarin and significantly fewer major bleeding events (2.0% versus 3.3%; RR, 0.62; 95% CI, 0.47–0.82) with DOACs compared to warfarin. Under an interrupted strategy, there was no significant difference between DOACs versus warfarin for stroke/systemic embolism (0.4% [41/9260] versus 0.5% [31/7168]; RR, 0.95; 95% CI, 0.59–1.55), major bleeding (2.1% versus 2.0%; RR, 1.05; 95% CI, 0.85–1.30), and death (0.7% versus 0.6%; RR, 1.24; 95% CI, 0.76–2.04). The studies were homogeneous (I2=0.0%) for all calculated pooled associations except for the RR of death in the interrupted strategy (I2=26.3%). Conclusions: The short-term safety and efficacy of DOACs and warfarin are not different in patients with nonvalvular atrial fibrillation periprocedurally. Under an uninterrupted anticoagulation strategy, DOACs are associated with a 38% lower risk of major bleeding compared with warfarin.

NATIONAL TRENDS OF PCI AND CONCURRENT MORTALITY IN PATIENTS ≥75 YEARS AGE HOSPITALIZED DUE TO ACUTE MYOCARDIAL INFARCTION

The national epidemiology and temporal trends of percutaneous coronary intervention (PCI) and concurrent mortality in patients ≥75 years hospitalized with acute myocardial infarction (AMI) is unknown. We sought to characterize the trend and outcome of this life saving procedure in this population

EFFICACY AND SAFETY OF PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS TREATMENT ON CHOLESTEROL LEVELS: A COMPREHENSIVE META-ANALYSIS OF ALL RANDOMIZED CLINICAL TRIALS

Recent clinical trials have demonstrated concomitant lipid lowering treatments (LLT) with Proprotein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9I) effective in reducing blood LDL levels in hypercholesterolemia. We conducted a meta-analysis to assess the efficacy and safety of PCSK9I. A