Safi U. Khan

Amiodarone, lidocaine, magnesium or placebo in shock refractory ventricular arrhythmia: A Bayesian network meta-analysis

ABSTRACT Recent evidence challenges, the superiority of amiodarone, compared to other anti‐arrhythmic medications, as the agent of choice in pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF). We conducted Bayesian network and traditional meta‐analyses to investigate the relative efficacies of amiodarone, lidocaine, magnesium (MgSO4) and placebo as treatments for pulseless VT or VF. Eleven studies [5200 patients, 7 randomized trials (4, 611 patients) and 4 non‐randomized studies (589 patients)], were included in this meta‐analysis. The search was conducted, from 1981 to February 2017, using MEDLINE, EMBASE and The Cochrane Library. Estimates were reported as odds ratio (OR) with 95% Credible Interval (CrI). Markov chain Monte Carlo (MCMC) modeling was used to estimate the relative ranking probability of each treatment group based on surface under cumulative ranking curve (SUCRA). Bayesian analysis demonstrated that lidocaine had superior effects on survival to hospital discharge, compared to amiodarone (OR, 2.18, 95% Cr.I 1.26–3.13), MgSO4 (OR, 2.03, 95% Cr.I 0.74–4.82) and placebo (OR, 2.42, 95% Cr.I 1.39–3.54). There were no statistical differences among treatment groups regarding survival to hospital admission/24 h (hrs) and return of spontaneous circulation (ROSC). Probability analysis revealed that lidocaine was the most effective therapy for survival to hospital discharge (SUCRA, 97%). We conclude that lidocaine may be the most effective anti‐arrhythmic agent for survival to hospital discharge in patients with pulseless VT or VF. HighlightsBoth the American Heart Association and the European Resuscitation Council guidelines suggest amiodarone as first‐line anti‐arrhythmic therapy in shock refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), with lidocaine as an alternative if amiodarone is unavailable.Recent reports have raised concerns regarding the superiority of amiodarone as the agent of choice for shockable cardiac arrest.These observations mandate re‐evaluation of evidence on effective anti‐arrhythmic therapy in shock refractory VT and VF.We performed traditional and Bayesian analyses to compare amiodarone, lidocaine, magnesium and placebo in shockable cardiac rhythms to update the evidence.

A meta-analysis of continuous positive airway pressure therapy in prevention of cardiovascular events in patients with obstructive sleep apnoea.

AimsnTo assess whether continuous positive airway pressure (CPAP) therapy reduces major adverse cardiovascular events (MACE) in patients with moderate-to-severe obstructive sleep apnoea (OSA).nnnMethods and resultsnA total of 235 articles were recovered using MEDLINE, EMBASE and Cochrane library (inception-December 2016) and references contained in the identified articles. Seven randomized controlled trials (RCTs) were selected for final analysis. Analysis of 4268 patients demonstrated non-significant 26% relative risk reduction in MACE with CPAP [risk ratio (RR) 0.74; 95% confidence interval (CI) 0.47-1.17; Pu2009=u20090.19, I2u2009=u200948%]. A series of sensitivity analyses suggested that increased CPAP usage time yielded significant risk reduction in MACE. and stroke. Subgroup analysis revealed that CPAP adherence time ≥4u2009hours (h)/night reduced the risk of MACE by 57% (RR 0.43; 95% CI 0.23-0.80; Pu2009=u20090.01, I2u2009=u20090%). CPAP therapy showed no beneficial effect on myocardial infarction (MI), all-cause mortality, atrial fibrillation/flutter (AF), or heart failure (HF) (Pu2009>u20090.05). CPAP had positive effect on mood and reduced the daytime sleepiness [Epworth Sleepiness Scale (ESS): mean difference (MD) -2.50, 95% CIu2009-u20093.62, -1.39; Pu2009<u20090.001, I2u2009=u200981%].nnnConclusionnCPAP therapy might reduce MACE and stroke among subjects with CPAP time exceeding 4u2009h/night. Additional randomized trials mandating adequate CPAP time adherence are required to confirm this impression.

Transcatheter vs surgical aortic-valve replacement in low- to intermediate-surgical-risk candidates: A meta-analysis and systematic review

The American and European expert documents recommend transcatheter aortic valve replacement (TAVR) for inoperable or high‐surgical‐risk patients with severe aortic stenosis. In comparison, efficacy of TAVR is relatively less studied in low‐ to intermediate‐surgical‐risk patients. We sought to discover whether TAVR can be as effective as surgical aortic valve replacement (SAVR) in low‐ to intermediate‐surgical‐risk candidates. Four randomized clinical trials (RCTs) and 8 prospective matched studies were selected using PubMed/MEDLINE, Embase, and Cochrane Library (inception: March 2017). Results were reported as random‐effects odds ratio (OR) with 95% confidence interval (CI). Among 9851 patients, analyses of RCTs showed that all‐cause mortality was comparable between TAVR and SAVR (short term, OR: 1.19, 95% CI: 0.86‐1.64, Pu2009=u20090.30; mid‐term, OR: 0.97, 95% CI: 0.75‐1.26, Pu2009=u20090.84; and long term, OR: 0.97, 95% CI: 0.81‐1.16, Pu2009=u20090.76). The analysis restricted to matched studies showed similar outcomes. In the analysis stratified by study design, no significant differences were noted in the RCTs for stroke, whereas TAVR was better than SAVR in matched studies at short term only (OR: 0.46, 95% CI: 0.33‐0.65, Pu2009<u20090.001). TAVR is associated with reduced risk of acute kidney injury and new‐onset atrial fibrillation (Pu2009<u20090.05). However, increased incidence of permanent pacemaker implantation and paravalvular leaks was observed with TAVR. TAVR can provide similar mortality outcome compared with SAVR in low‐ to intermediate‐surgical‐risk patients with critical aortic stenosis. However, both procedures are associated with their own array of adverse events.

Meta-Analysis of Anti-Thrombotic Therapy in Atrial Fibrillation after Percutaneous Coronary Intervention

Current clinical practice prefers oral anticoagulation (OAC) plus dual antiplatelet therapy (DAPT) in atrial fibrillation (AF) after percutaneous coronary intervention (PCI). We conducted a meta-analysis to test the hypothesis that the superiority of OAC plus DAPT is mainly endorsed by observational studies (OSs); conversely, randomized clinical trials (RCTs) have suggested that OAC plus a single antiplatelet (SAP) agent is a safer and equally effective approach. Nine studies (4 RCTs and 5 OSs) were selected using MEDLINE, EMBASE, and CENTRAL (Inception, October 31, 2017). In analysis of RCTs, OAC plus SAP was safer in terms of major bleeding compared with OAC plus DAPT (relative risk [RR] 0.70, 95% confidence interval [CI] 0.60 to 0.81, p <0.001). Conversely, analysis of OSs showed comparable risk of major bleeding among both groups (RR 0.92, 95% CI 0.65 to 1.29, pu2009=u20090.61). For major adverse cardiovascular events, RCTs restricted analysis (RR 0.93, 95% CI 0.68 to 1.27, pu2009=u20090.64) and analysis of OSs (RR 1.43, 95% CI 0.84 to 2.42, pu2009=u20090.19) showed similar outcomes between both strategies. Both regimens had a similar risk of myocardial infarction (MI) in RCTs restricted analysis (RR 1.18, 95% CI 0.89 to 1.56, pu2009=u20090.24); however, analysis of OSs showed 76% higher risk of MI with OAC plus SAP. In conclusion, in patients with AF after PCI, RCTs recommend OAC plus SAP for better safety and equal efficacy compared with OAC plus DAPT. These findings oppose the results of OSs that showed similar safety and reduced risk of MI with OAC plus DAPT.

Coronary artery perforation complicated by recurrent cardiac tamponade: a case illustration and review

Coronary artery perforation during percutaneous intervention is a rare but potentially life threatening complication. The treatment of coronary perforation can be challenging in view of potential life threatening consequences such as cardiac tamponade or myocardial infarction. Presented is a clinical course of a 69year-old female who developed cardiac tamponade as a result of presumed wire related perforation of the posterolateral branch of the right coronary artery. Her clinical course was further complicated by recurrent tamponade, atrial fibrillation, stress induced cardiomyopathy, heparin induced thrombocytopenia and cardiogenic pulmonary edema. Based on review of the medical literature a treatment algorithm for wire perforation is suggested.

Implantable cardioverter defibrillator in nonischemic cardiomyopathy: A systematic review and meta-analysis

The evidence to support implantable cardioverter defibrillator (ICD) in subjects with nonischemic cardiomyopathy (NICM) for primary prevention of sudden cardiac death (SCD) is not robust. This meta‐analysis intends to assess the impact of routine ICD implantation for primary prevention of mortality due to SCD in NICM based on all the published randomized clinical trials (RCTs). Six RCTs were selected using PubMed/Medline, EMBASE, and CENTRAL from inception to December 2016. Outcomes were calculated as random‐effects relative risk (RR) and risk difference (RD) with 95% confidence interval (CI). Patients were randomized to ICD arm and control arm (usual care, medical treatment, and anti‐arrhythmic drugs). ICD significantly reduced all‐cause mortality in NICM patients (RR, 0.74, 95% CI, 0.56‐0.97, P = .03, I2 = 40). Mortality benefit was achieved due to a significant reduction in sudden cardiac death (SCD) (RR, 0.47, 95% CI, 0.30‐0.73, P < .001, I2 = 0). There were no statistical differences between two groups with regard to risk of noncardiac mortality, non‐SCD, cardiac arrest, cardiac transplant, sustained ventricular tachycardia (VT), and VT requiring medical treatment. Our results support efficacy of ICDs at reducing all‐cause mortality due to a reduction in SCD.

The Clinical Benefits and Mortality Reduction Associated With Catheter Ablation in Subjects With Atrial Fibrillation: A Systematic Review and Meta-Analysis

OBJECTIVESnThis study sought to compare the efficacy and safety of catheter ablation (CA) with those of medical therapy (MT) for the treatment of atrial fibrillation (AF).nnnBACKGROUNDnThe preferred therapeutic strategy for subjects with AF remains unclear.nnnMETHODSnA total of 17 randomized controlled trials were selected using Medline, EMBASE, and CENTRAL (September 1998 to 2 February 2018). The analysis was stratified at the trial level according to the following: 1) patients with AF and heart failure (HF); and 2) patients with AF without HF.nnnRESULTSnA total of 2,272 patients with AF (775 patients with HF and 1,497 patients without HF) participated in this analysis. In patients with HF, CA was associated with significant relative risk reduction in all-cause mortality (risk ratio [RR]: 0.52; 95% confidence interval [CI]: 0.36 to 0.76; pxa0< 0.001; I2xa0= 0), recurrent atrial arrhythmia (RR: 0.44; 95% CI: 0.31 to 0.61; pxa0<0.001; I2xa0= 56), and cardiac hospitalization (RR: 0.63; 95% CI: 0.46 to 0.87; pxa0= 0.01; I2xa0= 43) compared with MT. Conversely, in patients without HF, CA had no beneficial effect on the risk of all-cause mortality compared with MT (RR: 0.88, 95% CI: 0.29 to 2.61; pxa0= 0.81; I2xa0= 0). However, CA reduced the risk of recurrent atrial arrhythmia (RR: 0.40; 95% CI: 0.31 to 0.52; pxa0< 0.001; I2xa0= 73) and cardiac hospitalization (RR: 0.32; 95% CI: 0.23 to 0.45; pxa0< 0.001; I2xa0= 0) in patients without HF.nnnCONCLUSIONSnThis meta-analysis suggests that although CA reduced the risk of cardiac hospitalization and recurrent atrial arrhythmia both in subjects with HF and in subjects without HF, the reduction in all-cause mortality was limited to subjects with HF only.

Percutaneous Coronary Intervention Versus Surgery in Left Main Stenosis–A Meta-Analysis and Systematic Review of Randomised Controlled Trials

OBJECTIVEnTo investigate the safety and efficacy of percutaneous coronary interventions (PCI) versus coronary artery bypass graft (CABG) surgery for left main coronary artery (LMCA) disease.nnnMETHODSnSix randomised controlled trials (RCTs) were reviewed by searching PubMed/Medline, Embase and the Cochrane Library. Estimates were pooled according to random effects model. Binary outcomes were reported as risk ratio (RR) and continuous outcomes were reported as mean difference (MD) with 95% confidence interval (CI).nnnRESULTSn3794 patients were randomised into PCI and CABG arms. Mean age of the total population was 64.7 years, 74.4% were male and mean Logistic EURO score (LES) was 2.9. When compared with CABG, patients treated with PCI had reduced risk of major adverse cardiovascular events (MACE) at 30 days: (RR: 0.55; 95% CI, 0.41-0.75; p<0.001; I2=0) but similar risk at 1year (RR: 1.15; 95% CI, 0.92-1.45; p=0.22; I2=0). Five years MACE rates favoured CABG (RR: 1.32; 95% CI, 1.13-1.53; p<0.001; I2=0) driven by a higher rate of target vessel revascularisation (TVR) (RR: 1.71; 95%CI, 1.38-2.12; p<0.001; I2=0) and myocardial infarction (MI) (RR: 1.97; 95%CI, 1.28-3.04; p<0.001; I2=22). Percutaneous coronary intervention was comparatively a safer procedure with lower rates of periprocedural adverse events including MI, stroke, bleeding events and need for blood transfusions.nnnCONCLUSIONnPercutaneous coronary intervention reduced MACE at 30days with comparable MACE at 1year. However, CABG was a more effective modality when considering mid- to long-term outcomes. PCI is a safer procedure with regards to periprocedural adverse events.

A Bayesian network meta-analysis of PCSK9 inhibitors, statins and ezetimibe with or without statins for cardiovascular outcomes

Background The comparative effects of statins, ezetimibe with or without statins and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors remain unassessed. Design Bayesian network meta-analysis was conducted to compare treatment groups. Methods Thirty-nine randomized controlled trials were selected using MEDLINE, EMBASE, and CENTRAL (inception – September 2017). Results In network meta-analysis of 189,116 patients, PCSK9 inhibitors were ranked as the best treatment for prevention of major adverse cardiovascular events (Surface Under Cumulative Ranking Curve (SUCRA), 85%), myocardial infarction (SUCRA, 84%) and stroke (SUCRA, 80%). PCSK9 inhibitors reduced the risk of major adverse cardiovascular events compared with ezetimibeu2009+u2009statin (odds ratio (OR): 0.72; 95% credible interval (CrI), 0.55–0.95; Grading of Recommendation Assessment, Development and Evaluation (GRADE) criteria: moderate), statin (OR: 0.78; 95% CrI: 0.62–0.97; GRADE: moderate) and placebo (OR: 0.63; 95% CrI: 0.49–0.79; GRADE: high). The PCSK9 inhibitors were consistently superior to groups for major adverse cardiovascular event reduction in secondary prevention trials (SUCRA, 95%). Statins had the highest probability of having lowest rates of all-cause mortality (SUCRA, 82%) and cardiovascular mortality (SUCRA, 84%). Compared with placebo, statins reduced the risk of all-cause mortality (OR: 0.88; 95% CrI: 0.83–0.94; GRADE: moderate) and cardiovascular mortality (OR: 0.84; 95% CrI: 0.77–0.90; GRADE: high). For cardiovascular mortality, PCSK9 inhibitors were ranked as the second best treatment (SUCRA, 78%) followed by ezetimibeu2009+u2009statin (SUCRA, 50%). Conclusion PCSK9 inhibitors were ranked as the most effective treatment for reducing major adverse cardiovascular events, myocardial infarction and stroke, without having major safety concerns. Statins were ranked as the most effective therapy for reducing mortality.

Arteriotomy site complication during transcatheter aortic valve replacement: Ipsilateral wire protection and bailout

Major vascular complications still occur in ~4.2% of transcatheter aortic valve replacement (TAVR) procedures. These complications are a major safety drawback of TAVR when compared to surgical aortic valve replacement (SAVR). Contemporary strategies designed to minimize and effectively treat vascular complications are of immense importance to a successful TAVR program. This review discusses strategies to optimize TAVR access and device choice along with TAVR access complication management. Iliac complications are less frequently encountered and can be managed effectively via the TAVR sheath over the TAVR wire employing ipsilateral proximal iliac balloon occlusion and endovascular repair. The more common arteriotomy site complications and access site closure failure require prophylactic or bail-out common femoral to superficial femoral artery wiring. Suggested is a novel method of ipsilateral arteriotomy site protection that is safe, simple and does not require additional resources. Ipsilateral wiring can also be done prophylactically or as a bailout in case of arteriotomy site complication.