Islam Y. Elgendy

Outcomes With Intravascular Ultrasound-Guided Stent Implantation: A Meta-Analysis of Randomized Trials in the Era of Drug-Eluting Stents.

Background—In the era of drug-eluting stents, it is unknown if intravascular ultrasound (IVUS) guidance for percutaneous coronary intervention should be routinely endorsed. This study aimed to determine if IVUS-guided stent implantation is associated with improved outcomes. Methods and Results—Randomized trials that reported clinical outcomes and compared routine IVUS-guided stent implantation with an angiography-guided approach in the era of drug-eluting stents were included. Summary estimates were constructed primarily using the Peto model. Seven trials with 3192 patients were analyzed. The mean length of the coronary lesions was 32 mm. At a mean of 15 months, routine IVUS-guided percutaneous coronary intervention was associated with a reduction in the risk of major adverse cardiac events (6.5% versus 10.3%; odds ratio, 0.60; 95% confidence interval, 0.46–0.77; P<0.0001), mainly because of reduction in the risk of ischemia-driven target lesion revascularization (4.1% versus 6.6%; odds ratio, 0.60; 95% confidence interval, 0.43–0.84; P=0.003). The risk of cardiovascular mortality (0.5% versus 1.2%; odds ratio, 0.46; 95% confidence interval, 0.21–1.00; P=0.05), and stent thrombosis (0.6% versus 1.3%; odds ratio, 0.49; 95% confidence interval, 0.24–0.99; P=0.04) also appeared to be lower in the IVUS-guided group. Conclusions—In the era of drug-eluting stents for diffuse coronary lesions, IVUS-guided percutaneous coronary intervention is superior to angiography-guided percutaneous coronary intervention in reducing the risk of major adverse cardiac events. This is primarily because of reduction in the risk of ischemia-driven target lesion revascularization. This analysis also suggests that risk of cardiovascular mortality and stent thrombosis might be lower with an IVUS-guided approach.

Is Aspiration Thrombectomy Beneficial in Patients Undergoing Primary Percutaneous Coronary Intervention? Meta-Analysis of Randomized Trials

Background—It is unclear whether intravenous glycoprotein IIb/IIIa inhibitors or ischemic time might modify any clinical benefits observed with aspiration thrombectomy before primary percutaneous coronary intervention (PCI) in patients with ST-segment–elevation myocardial infarction. Methods and Results—Electronic databases were searched for trials that randomized ST-segment–elevation myocardial infarction patients to aspiration thrombectomy before PCI versus conventional PCI. Summary estimates were constructed using a DerSimonian-Laird model. Seventeen trials with 20 960 patients were available for analysis. When compared with conventional PCI, aspiration thrombectomy was not associated with a significant reduction in the risk of mortality 2.8% versus 3.2% (risk ratio [RR], 0.89; 95% confidence interval [CI], 0.76–1.04; P=0.13), reinfarction 1.3% versus 1.4% (RR, 0.93; 95% CI, 0.73–1.17; P=0.52), the combined outcome of mortality or reinfarction 4.1% versus 4.6% (RR, 0.90; 95% CI, 0.79–1.02; P=0.11), or stent thrombosis 0.9% versus 1.2% (RR, 0.82; 95% CI, 0.62–1.08; P=0.15). Aspiration thrombectomy was associated with a nonsignificant increase in the risk of stroke 0.6% versus 0.4% (RR, 1.45; 95% CI, 0.96–2.21; P=0.08). Meta-regression analysis did not identify a difference for the log RR of mortality, reinfarction, and the combined outcome of mortality or reinfarction with intravenous glycoprotein IIb/IIIa inhibitors (P=0.17, 0.70, and 0.50, respectively) or with ischemic time (P=0.29, 0.66, and 0.58, respectively). Conclusions—Aspiration thrombectomy before primary PCI is not associated with any benefit on clinical end points and might increase the risk of stroke. Concomitant administration of intravenous glycoprotein IIb/IIIa inhibitors and ischemic time did not seem to influence any potential benefits observed with aspiration thrombectomy.

Cardiovascular outcomes with sodium–glucose cotransporter-2 inhibitors in patients with type II diabetes mellitus: A meta-analysis of placebo-controlled randomized trials

BACKGROUND The impact of sodium-glucose cotransporter-2 (SGLT-2) inhibitors on cardiovascular outcomes in patients with type II diabetes mellitus (DM) is not well established. METHODS We searched electronic databases from inception through July 2016 for randomized, placebo-controlled trials, involving SGLT-2 inhibitors. Fixed-effects summary odds ratios (OR) were constructed using Peto model. RESULTS Eighty-one trials with a total of 37,195 patients were included. The mean follow-up was 89weeks. Compared with placebo, SGLT-2 inhibitors were associated with a lower risk of all-cause mortality (OR 0.72; 95% CI 0.59-0.86; P<0.001), cardiovascular mortality (OR 0.67; 95% CI 0.53-0.84; P=0.001), and heart failure (OR 0.67; 95% CI 0.51-0.87; P=0.003), but a similar risk of myocardial infarction (OR 0.89; 95% CI 0.74-1.09; P=0.29) and stroke/transient ischemic attack (OR 1.09; 95% CI 0.87-1.37; P=0.47). The reduction in all-cause mortality was noticed with empagliflozin (OR 0.66; 95% CI 0.54-0.81; P<0.001), but not with other SGLT-2 inhibitors (ORdapagliflozin 1.37; 95% CI 0.71-2.62; P=0.35; ORcanagliflozin 0.82; 95% CI 0.41-1.68; P=0.59; ORluseogliflozin 4.6; 95% CI 0.07-284.25; P=0.47; and ORipragliflozin 4.73; 95% CI 0.08-283.14; P=0.46) (Pinteraction=0.19). Potential harm was observed with dapagliflozin on cardiovascular mortality (OR 2.15, 95% CI 0.92-5.04, P=0.08). CONCLUSIONS In patients with type II DM, SGLT-2 inhibitors appeared to reduce both all-cause and cardiovascular mortality, primarily due to reduction in the risk of heart failure. The benefit was only seen with empagliflozin. There was suggestion of potential harm with dapagliflozin, thus future trials are needed to ascertain the cardiovascular safety of other agents in this class.

Mechanical Thrombectomy for Acute Ischemic Stroke: A Meta-Analysis of Randomized Trials

BACKGROUND Acute ischemic stroke is a leading cause of serious disability and death worldwide. Individual randomized trials have shown possible benefits of mechanical thrombectomy after usual care compared with usual care alone (i.e., intravenous thrombolysis) in the management of acute ischemic stroke patients. OBJECTIVES This study systematically determined if mechanical thrombectomy after usual care would be associated with better outcomes in patients with acute ischemic stroke caused by large artery occlusion. METHODS The authors included randomized trials that compared mechanical thrombectomy after usual care versus usual care alone for acute ischemic stroke. Random effects summary risk ratios (RR) were constructed using a DerSimonian and Laird model. RESULTS Nine trials with 2,410 patients were available for analysis. Compared with usual care alone, mechanical thrombectomy was associated with a higher incidence of achieving good functional outcome, defined as a modified Rankin scale (mRS) of 0 to 2 (RR: 1.45; 95% confidence interval [CI]: 1.22 to 1.72; p < 0.0001) and excellent functional outcome defined as mRS 0 to 1 (RR: 1.67; 95% CI: 1.27 to 2.19; p < 0.0001) at 90 days. There was a trend toward reduced all-cause mortality with mechanical thrombectomy (RR: 0.86; 95% CI: 0.72 to 1.02; p = 0.09). The risk of symptomatic intracranial hemorrhage was similar with either treatment modality (RR 1.06: 95% CI: 0.73 to 1.55; p = 0.76). CONCLUSIONS In acute ischemic stroke due to large artery occlusion, mechanical thrombectomy after usual care was associated with improved functional outcomes compared with usual care alone, and was found to be relatively safe, with no excess in intracranial hemorrhage. There was a trend for reduction in all-cause mortality with mechanical thrombectomy.

Caseous calcification of the mitral annulus: a review.

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification (MAC). Since most cardiologists are unfamiliar with CCMA, it is commonly misdiagnosed as an abscess, tumor or infective vegetation on the mitral valve. In most cases, conservative management for this lesion is sufficient. In this review, we will discuss the various aspects of this condition and illustrate the gross and histologic pathology as well as various imaging modalities (Ultrasound, Computed tomography, Cardiac Magnetic resonance) to assess this unusual cardiac mass.

Transcatheter Patent Foramen Ovale Closure After Cryptogenic Stroke: An Updated Meta-Analysis of Randomized Trials

Paradoxical embolism from a patent foramen ovale (PFO) mediated right-to-left shunt is a well-described mechanism of ischemic stroke [(1)][1]. In a patient level meta-analysis of the earlier 3 randomized trials, percutaneous PFO closure was superior to medical therapy for secondary prevention of

Complete versus culprit-only revascularization in patients with multi-vessel disease undergoing primary percutaneous coronary intervention: A meta-analysis of randomized trials

BACKGROUND The best approach for revascularization of multi-vessel coronary disease in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) is controversial. METHODS We searched the Medline and Web of Science databases, the Cochrane Register of Controlled Trials, and major conference proceedings for clinical trials that randomized STEMI patients with multi-vessel disease to a complete versus culprit-only revascularization strategy. Random effects summary risk ratios (RR) were constructed using a DerSimonian-Laird model. RESULTS A total of 6 trials met our selection criteria, which yielded 1,190 patients. The mean follow-up duration was 20.5 months. The incidence of major adverse cardiac events was significantly reduced in the complete revascularization group versus the culprit-only revascularization group (RR 0.57, 95% confidence interval (CI) 0.41-0.78, p < 0.001). This was due to a lower risk of urgent revascularization with complete revascularization (RR 0.55, 95% CI 0.35-0.86, p = 0.01). A non-significant reduction was observed with complete versus culprit-only revascularization for the combined outcome of mortality or myocardial infarction (RR 0.56, 95% CI 0.30-1.04, p = 0.06). CONCLUSION Complete revascularization of significant coronary lesions at the time of primary PCI in patients with STEMI and multi-vessel disease was associated with better outcomes. This was primarily due to a reduction in the need for urgent revascularization. Larger trials are needed to determine if complete revascularization reduces death or myocardial infarction.

Fractional flow reserve: an updated review.

Revascularization of ischemia‐producing coronary lesions is widely used in the management of coronary artery disease. However, some coronary lesions appear significant on the conventional angiogram when they are truly non–flow limiting. For this reason, it is becoming increasingly important to determine the coronary physiology. Fractional flow reserve (FFR) has emerged as a useful tool to determine the lesions that require revascularization. Measurement of FFR during invasive coronary angiography now has a class IA indication from the European Society of Cardiology for identifying hemodynamically significant coronary lesions when noninvasive evidence of myocardial ischemia is unavailable. Current data on FFR can be broadly classified into studies that compare the diagnostic accuracy of FFR measurement compared with other noninvasive modalities and studies that test treatment strategies of patients with intermediate coronary stenoses using a threshold value for FFR and that have clinical outcomes as endpoints. In this review, we will discuss the concept of FFR, current evidence supporting its usage, and future perspectives.

Complete Versus Culprit-Only Revascularization for Patients With Multi-Vessel Disease Undergoing Primary Percutaneous Coronary Intervention: An Updated Meta-Analysis of Randomized Trials: Complete versus Culprit PCI in STEMI

To perform an updated meta‐analysis to determine whether complete revascularization of significant coronary lesions at the time of primary percutaneous coronary intervention (PCI) would be associated with better outcomes compared with culprit‐only revascularization.

Efficacy and safety of angiotensin receptor blockers in older patients: a meta-analysis of randomized trials.

BACKGROUND The efficacy and safety of angiotensin receptor blockers (ARBs) in the older population is unclear. OBJECTIVES To determine the efficacy and safety of ARBs in older patients. METHODS Randomized trials that compared ARBs to control and reported clinical outcomes in patients with a mean age of 65 years or older were included. Random-effects summary risk ratios (RRs) were constructed. RESULTS A total of 16 trials met our selection criteria, which yielded 113,386 patients. ARBs were associated with a marginal increased risk of all-cause mortality (RR: 1.03, 95% confidence interval (CI): 1.00-1.06, P = 0.05), a nonsignificant increased risk of myocardial infarction (RR: 1.04, 95% CI: 0.96-1.12, P = 0.36), a marginal reduction in heart failure hospitalization (RR: 0.86, 95% CI: 0.74-1.00, P = 0.06), and a significant reduction in the risk of stroke (RR: 0.93, 95% CI: 0.87-0.99, P = 0.03). ARBs were associated with an increased risk of acute kidney injury (RR: 1.48, 95% CI: 1.24-1.77, P < 0.001), hypotension (RR: 1.56, 95% CI: 1.24-1.97, P < 0.001), and hyperkalemia (RR: 1.57, 95% CI: 1.13-2.19, P = 0.008). On the sensitivity analysis including placebo-controlled trials, the risk of all-cause mortality was no longer significant (P = 0.2), while the remainder of the outcomes did not change. CONCLUSION In older patients, the benefit of ARBs compared with control was strongest for stroke reduction, with no (or weak) associations for all-cause mortality, myocardial infarction, and heart failure hospitalization. Benefit was offset by an increased risk of acute kidney injury, hypotension, and hyperkalemia. Thus, ARBs should be used with caution in older patients when clinically indicated.