The aim of the study was to compare the efficacy of revascularization versus medical therapy in patients with atherosclerotic renal artery stenosis (ARAS). ARAS is the most common cause of secondary ...hypertension and is associated with several complications, such as renal failure, coronary artery disease, cardiac destabilization, and stroke. Medical therapy is the cornerstone for management of ARAS; however, numerous trials have compared medical therapy with revascularization in the form of percutaneous renal artery angioplasty (PTRA) or percutaneous renal artery angioplasty with stent placement (PTRAS). Medline (PubMed and Ovid SP), Embase, Cochrane Central Register of Controlled Clinical Trials (CENTRAL), and Cochrane Database of Systematic Review (CDSR) were searched till present (November 2013) to identify clinical trials where medical therapy was compared with revascularization (PTRA or PTRAS). We performed a meta-analysis using a random effects model. The heterogeneity was assessed using I2 values. The initial database search identified 540 studies and 7 randomized controlled trials, and 2,139 patients were included in the final analysis. Angioplasty with or without stenting was not superior to medical therapy with respect to any outcome. The incidence of nonfatal myocardial infarction was 6.74% in both the stenting and medical therapy group (odds ratio = 0.998, 95% confidence interval 0.698 to 1.427, p = 0.992), and incidence of renal events in stenting population was found to be 19.58% versus 20.53% in medical therapy (odds ratio = 0.945, 95% confidence interval 0.755 to 1.182, p = 0.620). In conclusion, PTRA or PTRAS does not improve outcomes compared with medical therapy in patients with ARAS. Future studies should investigate to identify patient subgroups that may benefit from such an intervention.
Total occlusion (TO) of the culprit artery usually presents with ST-elevation myocardial infarction. A subset of patients with TO present as non-ST segment elevation myocardial infarction (NSTEMI) ...without classic ST-elevation on the electrocardiogram. This may lead to delay in identification of these patients and further management. We performed a meta-analysis to estimate the difference in outcomes between totally occluded and non-occluded culprit arteries in patients with NSTEMI.
Our literature search yielded seven studies with 40 777 patients. The outcomes assessed were clinical presentation (Killip class), left ventricular ejection fraction, time to angiography, major cardiac adverse events (MACE) and all-cause mortality. The generic inverse or Mantel-Haenszel method was used to pool relevant outcomes and the mean difference (MD) or relative risk (RR) was calculated. A total of 10 415 (25.5%) patients had an occluded culprit artery with a predominant infero-lateral distribution (40% right coronary and 33% left circumflex artery). There was an increased risk of both MACE (short-term RR: 1.41; CI: 1.17, 1.70; P = 0.0003; I2 = 26%; medium- to long-term RR: 1.32; CI: 1.11, 1.56; P = 0.001; I2 = 25%) and all-cause mortality (short-term RR: 1.67; CI: 1.31, 2.13; P < 0.0001; I2 = 41%; medium to long-term RR: 1.42; CI: 1.08, 1.86; P = 0.01; I2 = 32%) with TO of the culprit artery.
Our meta-analysis suggests that patients with NSTEMI who demonstrate a totally occluded culprit vessel on coronary angiography are at higher risk of mortality and major adverse cardiac events. Better risk stratification tools are needed to identify such high-risk acute coronary syndrome patients to facilitate earlier revascularization and potentially to improve outcomes.
If that is the case, all the other factors that can potentially bias an observation are distributed equally. ...any differences in the endpoints in the population of interest are deemed to be due to ...the allele of interest. ...the effect of the alleles of interest is seen after a lifelong exposure in a Mendelian randomized study, whereas the results of the drug effects depend upon the study duration. ...the effect size predicted by a Mendelian randomized study may be considerably higher than that seen in a clinical trial. ...while Mendelian randomized studies are useful for hypothesis generation, drugs in clinical trials frequently have “off-target” effects that cannot be predicted based on a Mendelian randomization study.
Abstract The number of meta-analyses published annually has increased more than 20-fold between 1994 (n = 386) and 2014 (n = 8203). In examining how much of this increase in meta-analysis publication ...has genuinely represented novel contributions to clinical medicine and public health, it became clear that there was an abundance of redundant and disorganized meta-analyses, creating confusion and generating considerable debate. Ironically, meta-analyses, which should prevent redundant research, have become a victim of it. Recently, 17 meta-analyses were published based on the results of only 3 randomized controlled trials that studied the role of transcatheter closure of patent foramen ovale for prevention of cryptogenic stroke. In our search of the published literature, we identified at least 10 topics that were the subject of 10 meta-analyses. In the context of overlapping meta-analyses, one questions what needs to be done to put this “runaway train” back on track. In this review we examine the practice of redundant meta-analyses and the reasons for its disturbing “popularity.” The registration of systematic reviews should be mandatory in prospective registries, such as PROSPERO, and the PRISMA checklist should be updated to incorporate new evidence and mandate the reference of previously published reviews and rationale for any new study.
Nearly 50% of patients undergoing coronary artery bypass grafting have diabetes. However, little is known about the influence of diabetes on long-term patency of bypass grafts. Because patients with ...diabetes have more severe coronary artery stenosis, we hypothesized that graft patency is worse in patients with than without diabetes.
This study sought to examine the influence of diabetes on long-term patency of bypass grafts.
From 1972 to 2011, 57,961 patients underwent primary isolated coronary artery bypass grafting. Of these, 1,372 pharmacologically treated patients with diabetes and 10,147 patients without diabetes had 15,887 postoperative angiograms; stenosis was quantified for 7,903 internal thoracic artery (ITA) grafts and 20,066 saphenous vein grafts. Status of graft patency across time was analyzed by longitudinal nonlinear mixed-effects modeling.
ITA graft patency was stable over time and similar in patients with and without diabetes: at 1, 5, 10, and 20 years, 97%, 97%, 96%, and 96% in patients with diabetes, and 96%, 96%, 95%, and 93% in patients without diabetes, respectively (early p = 0.20; late p = 0.30). In contrast, saphenous vein graft patency declined over time and similarly in patients with and without diabetes: at 1, 5, 10, and 20 years, 78%, 70%, 57%, and 42% in patients with diabetes, and 82%, 72%, 58%, and 41% in patients without diabetes, respectively (early p < 0.002; late p = 0.60). After adjusting for patient characteristics, diabetes was associated with higher early patency of ITA grafts (odds ratio: 0.63; 95% confidence limits: 0.43 to 0.91; p = 0.013), but late patency of ITA grafts was similar in patients with and without diabetes (p = 0.80). Early and late patency of saphenous vein grafts were similar in patients with and without diabetes (early p = 0.90; late p = 0.80).
Contrary to our hypothesis, diabetes did not influence long-term patency of bypass grafts. Use of ITA grafts should be maximized in patients undergoing coronary artery bypass grafting because they have excellent patency in patients with and without diabetes even after 20 years.
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...despite exhaustive investigations, the etiology behind a considerable proportion of these strokes remains uncertain and therefore many strokes are termed “cryptogenic”. Since the prevalence of ...Patent Foramen Ovale (PFO) is much higher in patients with cryptogenic strokes than the general population, it is logical to hypothesize that the closure of PFO will result in reduced incidence of recurrent strokes in patients. New England Journal of Medicine recently published 2 new randomized controlled trials (REDUCE and CLOSE) and the long-term outcomes of a third clinical trial (RESPECT) 1-3. ...the CLOSE trial followed 663 patients with a history of ischemic stroke and presence of a large inter-atrial shunt or an atrial aneurysm for a median of 5.3 years 2.
Abstract Statin intolerance is reported in 5-20% of patients and is a common cause for drug discontinuation. The prevalence of intolerance varies widely depending on the definitions used and the ...patient populations studied. Stopping statin therapy is associated with worse outcomes in patients with cardiovascular disease (CVD). Despite extensive study, the benefits and risks of statins continue to be debated by clinicians and the lay public. We searched the PubMed/Medline and Cochrane database of controlled trials (CENTRAL) database for all randomized controlled trials (RCTs) of statins compared with placebo. Studies were included if they had ≥1000 participants, followed patients for ≥1 year and reported rates of drug discontinuation. Studies were pooled as per the random effects model. A total of 22 studies (Statins=66024, Placebo=63656) met inclusion criteria. The pooled analysis showed that over a mean follow-up of 4.1 years, the rates of discontinuation were 13.3% (8872 patients) for statin-treated and 13.9% (8898 patients) for placebo-treated patients. The random effects model showed no significant difference between the placebo and statin arms (OR=0.99, 95% CI= 0.93-1.06). The results were similar for both primary prevention (OR=0.98, 95% CI= 0.92-1.05, p=0.39) and secondary prevention studies (OR= 0.92, 95% CI=0.83-1.05, p=0.43). The pooled analysis suggested that the rates of myopathy were also similar between the statins and placebos (OR=1.2, 95% CI= 0.88-1.62, p= 0.25). In conclusion, this meta-analysis of >125,000 patients suggests that the rate of drug discontinuation and myopathy does not significantly differ between statin- and placebo-treated patients in RCTs. These findings are limited by heterogeneity of results, variable duration of follow-up and lower doses of statins compared with contemporary clinical practice.
Background
The effects of increasing high-density lipoprotein cholesterol on cardiovascular outcomes remain uncertain.
Design
We conducted a meta-analysis to investigate the effects of high-density ...lipoprotein cholesterol modifiers (niacin, fibrates and cholesteryl ester transfer protein inhibitors) on cardiovascular outcomes.
Methods
Thirty-one randomized controlled trials (154,601 patients) with a follow-up of 6 months or more and a sample size of 100 or more patients were selected using MEDLINE, EMBASE and CENTRAL database (inception January 2018).
Results
High-density lipoprotein cholesterol modifiers had no statistically significant effect on cardiovascular mortality in terms of relative risk (RR) (RR 0.94, 95% confidence interval (CI) 0.89–1.00, P = 0.05, I2 = 13%) or absolute risk (risk difference −0.0001, 95% CI −0.0014, 0.0011, P = 0.84, I2 = 28%). High-density lipoprotein cholesterol modifiers reduced the RR of myocardial infarction (RR 0.87, 95% CI 0.82–0.93, P < 0.001, I2 = 37%). This significant effect was derived by the use of fibrates (RR 0.80, 95% CI 0.73–0.87, P < 0.001, I2 = 22%) and meta-regression analysis showed that this benefit was consistent with an absolute reduction in low-density lipoprotein cholesterol. High-density lipoprotein cholesterol modifiers had no effect on stroke (RR 1.00, 95% CI 0.93–1.09, P = 0.94, I2 = 25%) or all-cause mortality (RR 1.02, 95% CI 0.97–1.08, P = 0.48, I2 = 49%). Meta-regression analyses failed to demonstrate a significant association of pharmacologically increased high-density lipoprotein cholesterol with key endpoints. In studies with background statin therapy, high-density lipoprotein cholesterol modifiers had no statistically significant impact on cardiovascular mortality, myocardial infarction, stroke or all-cause mortality (P > 0.05).
Conclusion
The use of high-density lipoprotein cholesterol modifying treatments had no significant effect on cardiovascular mortality, stroke or all-cause mortality. The beneficial effect on myocardial infarction was lost when drugs were used with statin therapy.
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