Khagendra Dahal

Comparison of prasugrel and ticagrelor in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A meta-analysis of randomized and non-randomized studies

BACKGROUNDnThe newer oral P2Y12 receptor antagonists (i.e. prasugrel and ticagrelor) are recommended over clopidogrel for patients with acute coronary syndrome (ACS) going for percutaneous coronary intervention (PCI). As the superiority of one agent over the other remains unclear, we designed a systematic review and meta-analysis of these agents in patients with ACS undergoing PCI.nnnMETHODSnPUBMED, EMBASE, Cochrane CENTRAL, CINAHL and manual search were performed through 11/02/2016. Mortality, myocardial infarction (MI), stroke, repeat revascularization, stent thrombosis (ST) and BARC bleeding ≥2 were the major outcomes.nnnRESULTSnA total of 9 studies with 21,360 total patients were included in the meta-analysis. Compared to ticagrelor, prasugrel was associated with lower rate of MI [0.8% vs. 1.9%; 0.54 (0.29-0.99); P=0.05] but no difference was noted in mortality [2.1% vs. 2.4%; 0.84 (0.64-1.09); P=0.19], repeat revascularization [1.6% vs. 2.1%; 0.82 (0.61-1.10); P=0.19] and stroke [0.2% vs. 0.3%; 0.68 (0.25-1.83); P=0.44] between two agents. In addition, prasugrel was associated with lower risk of BARC ≥2 bleeding [2.5% vs. 3.8%; 0.75 (0.59-0.95); P=0.02] and showed a trend toward a lower risk of ST [0.3% vs. 0.6%; 0.55 (0.28-1.07); P=0.08] in comparison with ticagrelor.nnnCONCLUSIONSnBased on this meta-analysis of observational and randomized studies, prasugrel appears to be equivalent or superior to ticagrelor in patients with ACS undergoing PCI on the 30-day follow up. Larger randomized trials with longer follow-ups are needed to establish superiority of one agent over the other.

Aldosterone Antagonist Therapy and Mortality in Patients With ST-Segment Elevation Myocardial Infarction Without Heart Failure: A Systematic Review and Meta-analysis

Importance Treatment with aldosterone antagonists is recommended and has been shown to have beneficial effects in patients with ST-segment elevation myocardial infarction (STEMI) and left ventricular ejection fraction (LVEF) less than 40%. However, the role of aldosterone antagonists in patients with ejection fraction greater than 40% or without congestive heart failure is not well known. Objectives To perform a systematic review and meta-analysis using standard techniques to determine the role of therapy with aldosterone antagonists in this patient population. Data Sources PubMed, Embase, CINAHL, and Cochrane Central databases were searched and a manual search for relevant references from the selected articles and published reviews was performed from database inception through June 2017. Study Selection Randomized clinical trials that evaluated treatment with aldosterone antagonists in patients with STEMI without clinical heart failure or LVEF greater than 40% were included. Data Extraction and Synthesis Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to conduct and report the meta-analysis, which used a random-effects model. Two investigators independently performed the database search and agreed on the final study selection. A manual search was performed for relevant references from the selected articles and published reviews. Main Outcomes and Measures The outcomes analyzed were mortality, new congestive heart failure, recurrent myocardial infarction, ventricular arrhythmia, and changes in LVEF, serum potassium level, and creatinine level at follow-up. Results In all, 10 randomized clinical trials with a total of 4147 unique patients were included in the meta-analysis. In patients who presented with STEMI without heart failure, treatment with aldosterone antagonists compared with control was associated with lower risk of mortality (2.4% vs 3.9%; odds ratio [OR], 0.62; 95% CI, 0.42-0.91; Pu2009=u2009.01) and similar risks of myocardial infarction (1.6% vs 1.5%; OR, 1.03; 95% CI, 0.57-1.86; Pu2009=u2009.91), new congestive heart failure (4.3% vs 5.4%; OR, 0.82; 95% CI, 0.56-1.20; Pu2009=u2009.31), and ventricular arrhythmia (4.1% vs 5.1%; OR, 0.76; 95% CI, 0.45-1.31; Pu2009=u2009.33). Similarly, treatment with aldosterone antagonists compared with control was associated with a small yet significant increase in LVEF (mean difference, 1.58%; 95% CI, 0.18%-2.97%; Pu2009=u2009.03), a small increase in serum potassium level (mean difference, 0.07 mEq/L; 95% CI, 0.01-0.13 mEq/L; Pu2009=u2009.02), and no change in serum creatinine level (standardized mean difference, 1.4; 95% CI, −0.43 to 3.24; Pu2009=u2009.13). Conclusions and Relevance Treatment with aldosterone antagonists is associated with a mortality benefit in patients with STEMI with LVEF greater than 40% or without heart failure.

Non-vitamin K antagonists oral anticoagulants are as safe and effective as warfarin for cardioversion of atrial fibrillation: A systematic review and meta-analysis

BACKGROUNDnCurrent guidelines recommend anticoagulation using warfarin with bridging parenteral anticoagulation or one of the non-vitamin K antagonist oral anticoagulants (NOACs) to prevent thromboembolic events in patients undergoing cardioversion for atrial fibrillation (AF). We aimed to compare by meta-analytical techniques, the safety and efficacy of NOACs versus warfarin in patients undergoing cardioversion.nnnMETHODSnPUBMED, EMBASE, Cochrane CENTRAL and CINAHL were searched electronically in addition to manual search for randomized controlled trials (RCTs) comparing NOACs and warfarin in patients undergoing cardioversion for AF. Mortality, major bleeding and ischemic and hemorrhagic stroke were compared between the two agents.nnnRESULTSnA total of 7 trials with 7588 total patients were included in the meta-analysis. NOACs, as compared to warfarin, resulted in similar risk of ischemic stroke [odds ratio (OR): 0.49 (95% confidence interval (CI): 0.20-1.19; Pu202f=u202f0.12], major bleeding [0.71 (0.37-1.38), Pu202f=u202f0.32], mortality [0.73 (0.32-1.67); Pu202f=u202f0.45], and hemorrhagic stroke [0.96 (0.11-8.70); Pu202f=u202f0.97]. The results were consistent across subgroup analyses.nnnCONCLUSIONSnBased on the current meta-analysis, NOACs and warfarin have comparable efficacy and safety in patients with atrial fibrillation undergoing cardioversion.

Meta-Analysis Comparing Outcomes of Smokers Versus Nonsmokers With Acute Coronary Syndrome Underwent Percutaneous Coronary Intervention

Several studies have found improved mortality in smokers after acute coronary syndrome (ACS) especially in the thrombolytic era. We aimed to assess the association of smoking status with mortality and cardiovascular outcomes in patients with ACS treated with percutaneous coronary intervention (PCI). We searched PubMed, EMBASE, CINAHL, and Cochrane CENTRAL for randomized controlled trials since inception through February 15, 2018 and used random effects model for analysis. The outcomes analyzed were all-cause mortality, major adverse cardiac events (MACE), myocardial infarction, and target vessel revascularization at 1 month and 1 year. We included 17 randomized and nonrandomized studies with a total of 55,491 patients with 21,989 smokers and 33,502 nonsmokers. In ACS patients treated with PCI, smokers were found to have lower mortality than nonsmokers at 30-day ([2.3% vs 3.3%; Odds ratio; 0.54; 95% confidence interval: 0.39 to 0.76; p <0.001, I2u202f=u202f74%] and 1-year [2.3% vs 3.6%; Odds ratio 0.54 (0.3 to 0.7); p <0.001, I2u202f=u202f77%]. Meta-regression showed lower mortality in smokers was associated with younger age, man gender, and lower prevalence of diabetes mellitus. No significant differences were observed in myocardial infarction, MACE, and target-vessel revascularization between smokers and nonsmokers. In conclusion, smoking is associated with lower mortality but not MACE in ACS patients treated with PCI at 1-month and 1-year. This association with mortality was strongly associated with younger age, man gender, prevalence of diabetes mellitus, and extent of coronary artery disease.