Meta-Analysis Design and Results in Real Life: Problem Solvers or Detour to Maze. A Critical Review of Meta-Analysis of DAPT Randomized Controlled Trials.

Therapeutic strategies - such as duration of dual antiplatelet therapy after coronary artery stenting - usually generate a large quantity of meta-analyses. The meta-analyses that include the same randomized clinical trials should produce similar results. Our aim in the study is to analyze the quality and to compare the results of meta-analyses focused on a controversial topic such as dual antiplatelet therapy after percutaneous coronary intervention. We searched all published meta-analyses published up to November 2015 (near DAPT trial publication) selecting those that included the same randomized clinical trials comparing patterns of briefer versus longer-term double antiplatelet therapy. Seventeen meta-analyses achieved our selection criteria. Of the seventeen analyzed, we identified seven (41.1%) based on the same ten randomized clinical trials (RCTs), yet their results varied widely. Many of the meta-analyses differed in only some minor aspect of the design (i.e. eligible studies, length of comparators and statistical methods used). Some authors differed in the number of patients participating in RCTs and even, despite reviewing the same underlying trials, only 2 of the 7 meta-analyses included the same number of patients. Meta-analyses around cardiovascular, all-cause or non-cardiovascular death differ frequently. In the DAPT duration setting, several meta-analyses have been recently published based on the same data, presenting several issues making it difficult to determine clear recommendations on certain points.IN receives research funding from Astrazeneca; has received minor consulting fees from Boston, Medtronic, Astrazeneca; and speaking fees or support for attending scientificmeetings fromBoehringer, Daiichi-Sankyo, Lilly, AstraZeneca and Pfizer. AE is Astrazeneca employee. HB receives research funding from the Instituto de Salud Carlos III (PIE16/00021), AstraZeneca, BMS, Janssen and Novartis; has received consulting fees from Abbott, AstraZeneca, Bayer, BMS-Pfizer, Novartis; and speaking fees or support for attending scientificmeetings from AstraZeneca, Bayer, BMS-Pfizer, Ferrer, Novartis, Servier and MEDSCAPE-the heart.og. The other authors pose no relevant disclosures regarding this manuscript.S

Risk prediction of major cardiac adverse events and all-cause death following covid-19 hospitalization at one year follow-up: The HOPE-2 score

Background: Long -term consequences of COVID-19 are still partly known. Aim of the study: To derive a clinical score for risk prediction of long-term major cardiac adverse events (MACE) and all cause death in COVID-19 hospitalized patients. Methods: 2573 consecutive patients were enrolled in a multicenter, international registry (HOPE-2) from January 2020 to April 2021 and identified as the derivation cohort. Five hundred and twenty-six patients from the CardioCovid-Italy registry were considered as external validation cohort. A long-term prognostic risk score for MACE and all cause death was derived from a multivariable regression model. Results: Out of 2573 patients enrolled in the HOPE-2 registry, 1481 (58 %) were male, with mean age of 60 +/- 16 years. At long-term follow-up, the overall rate of patients affected by MACE and/or all cause death was 7.8 %. After multivariable regression analysis, independent predictors of MACE and all cause death were identified. The HOPE-2 prognostic score was therefore calculated by giving: 1 -4 points for age class ( = 85), 3 points for history of cardiovascular disease, 1 point for hypertension, 3 points for increased troponin serum levels at admission and 2 points for acute renal failure during hospitalization. Score accuracy at ROC curve analysis was 0.79 (0.74 at external validation). Stratification into 3 risk groups ( 6 points) classified patients into low, intermediate and high risk. The observed MACE and all-cause death rates were 1.9 %, 9.4 % and 26.3 % for low- intermediate and high-risk patients, respectively (Log-rank test p < 0.01). Conclusions: The HOPE-2 prognostic score may be useful for long-term risk stratification in patients with previous COVID-19 hospitalization. High-risk patients may require a strict follow-up

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Prognostic value of first fasting glucose measurement compared with admission glucose level in patients with acute coronary syndrome

Estudio observacional unicéntrico que analizó 547 pacientes consecutivos ingresados por un síndrome coronario agudo. Se evaluaron los niveles de glucemia en varios puntos como fueron durante el ingreso y la primera glucemia en ayunas. El estudio concluyó que es la primera glucemia en ayunas y no al ingreso el parámetro que se relaciona con un factor de riesgo independiente de eventos cardiovasculares (muerte o reinfarto) durante la hospitalización.Depto. de MedicinaFac. de MedicinaTRUEpu

Can resistance to aspirin be reversed after an additional dose?

Estudio observacional donde se evaluó en 141 pacientes con enfermedad coronaria estable en tratamiento crónico con aspirina 100mg al día si una dosis adicional reduce el porcentaje de pacientes no respondedores al tratamiento antiagregante. Tras una dosis “extra” de aspirina 100mg, el número de pacientes no respondedores a la inhibición plaquetaria con aspirina se redujo un 15% (del 50,7 al 35%).Aspirin resistance or aspirin non-responsiveness is a recently described phenomenon which has been consistently associated with an increased risk of cardiovascular events. This study was designed to determine the effects of an additional dose of 100 mg of aspirin on platelet function and proportion of aspirin non-responders using the platelet function analyzer-100 (PFA-100), in a well characterized population of stable coronary heart disease patients already on long-term aspirin treatment. Platelet function was assessed using PFA-100 in 141 patients (64.8 ± 10.1 years, 87.9% men) on long-term aspirin treatment (100 mg/day) before and 1 h after “in site” oral aspirin administration (100 mg). Prevalence of aspirin non-responders using PFA-100 was 50.7% (95% confidence interval 42.4–59). One hour after 100 mg of oral aspirin, reassessment of aspirin effects showed a prevalence of non-responders using PFA of 35.0% (95% CI 27.3–43.2) (P < 0.001 vs. pre-dose proportion). Using the PFA-100 system, reassessment of platelet function following oral administration of daily aspirin dosage significantly reduces the number of stable coronary disease patients considered to be non-responders to such treatment.Depto. de MedicinaFac. de MedicinaTRUEpu

Sepsis of Patients Infected by SARS-CoV-2: Real-World Experience From the International HOPE-COVID-19-Registry and Validation of HOPE Sepsis Score

Background: Patients with sepsis with a concomitant coronavirus (COVID-19) infection are related to a high morbidity and mortality rate. We investigated a large cohort of patients with sepsis with a concomitant COVID-19, and we developed a risk score for the estimation of sepsis risk in COVID-19. Methods: We conducted a sub-analysis from the international Health Outcome Predictive Evaluation Registry for COVID-19 (HOPE-COVID-19-Registry, NCT04334291). Out of 5,837 patients with COVID-19, 624 patients were diagnosed with sepsis according to the Sepsis-3 International Consensus. Results: In multivariable analysis, the following risk factors were identified as independent predictors for developing sepsis: current smoking, tachypnoea (>22 breath per minute), hemoptysis, peripheral oxygen saturation (SpO2) 1.5 mg/dl. By assigning odds ratio (OR) weighted points to these variables, the following three risk categories were defined to develop sepsis during admission: low-risk group (probability of sepsis 3.1–11.8%); intermediate-risk group (24.8–53.8%); and high-risk-group (58.3–100%). A score of 1 was assigned to current smoking, tachypnoea, decreased SpO2, decreased BP, decreased GCS, elevated PCT, TnI, and creatinine, whereas a score of 2 was assigned to hemoptysis. Conclusions: The HOPE Sepsis Score including nine parameters is useful in identifying high-risk COVID-19 patients to develop sepsis. Sepsis in COVID-19 is associated with a high mortality rate.Sin financiación5.058 JCR (2021) Q2, 53/172 Medicine General & Internal1.179 SJR (2021) Q1, 338/2489 Medicine (Miscellaneous)No data IDR 2021UE

Circadian variations of infarct size in acute myocardial infarction

Estudio retrospectivo unicéntrico que evaluó a 811 pacientes con un infarto agudo de miocardio. El estudio comparó el momento en el que presentaron el evento con el tamaño del infarto. Se pudo comprobar que los infartos fueron mas grandes en pacientes que lo padecieron durante la transición noche-día (entre las 6.00 y 12.00 am), resultados que ayudaron a interpretar el efecto cardioprotector de otras estrategias terapéuticas en pacientes con infarto de miocardio en ensayos clínicos posteriores.Background: The circadian clock influences a number of cardiovascular (patho)physiological processes including the incidence of acute myocardial infarction. A circadian variation in infarct size has recently been shown in rodents, but there is no clinical evidence of this finding. Objective: To determine the impact of time-of-day onset of ST segment elevation myocardial infarction (STEMI) on infarct size. Methods: A retrospective single-centre analysis of 811 patients with STEMI admitted between 2003 and 2009 was performed. Infarct size was estimated by peak enzyme release. The relationship between peak enzyme concentrations and time-of-day were characterised using multivariate regression splines. Time of STEMI onset was divided into four 6-hour periods in phase with circadian rhythms. Results: Model comparisons based on likelihood ratio tests showed a circadian variation in infarct size across time-of-day as evaluated by peak creatine kinase (CK) and troponin-I (TnI) concentrations (p=0.015 and p=0.012, respectively). CK and TnI curves described similar patterns across time, with a global maximum in the 6:00-noon period and a local minimum in the noon-18:00 period. Infarct size was largest in patients with STEMI onset in the dark-to-light transition period (6:00-noon), with an increase in peak CK and TnI concentrations of 18.3% (p=0.031) and 24.6% (p=0.033), respectively, compared with onset of STEMI in the 18:00-midnight period. Patients with anterior wall STEMI also had significantly larger infarcts than those with STEMI in other locations. Conclusions: Significant circadian oscillations in infarct size were found in patients according to time-of-day of STEMI onset. The infarct size was found to be significantly larger with STEMI onset in the dark-to-light transition period (6:00-noon). If confirmed, these results may have a significant impact on the interpretation of clinical trials of cardioprotective strategies in STEMIDepto. de MedicinaFac. de MedicinaTRUEpu

Prognostic Implications of Bundle Branch Block in Patients Undergoing Primary Coronary Angioplasty in the Stent Era

Estudio observacional unicéntrico que evaluó a 913 pacientes con infarto agudo de miocardio con elevación del segmento ST tratados con angioplastia primaria. Se analizaron los trazados electrocardiográficos para valorar aquellos pacientes que se presentaron con un bloqueo de rama (derecha / izquierda) y si tras la reperfusión, éste desaparece o permanece. El estudio concluye que los pacientes con bloqueo de rama persistente fueron aquellos con peor pronóstico.The presence of bundle branch block (BBB) in patients with ST-segment elevation myocardial infarction has been associated with a poor outcome. However, the implications of BBB in patients undergoing primary angioplasty in the stent era are poorly established. Furthermore, the prognostic implications of BBB type (right vs left and previous vs transient or persistent) remain unknown. We analyzed the data from 913 consecutive patients with ST-segment elevation myocardial infarction treated with primary angioplasty. All clinical, electrocardiographic, and angiographic data were prospectively collected. The median follow-up period was 19 months. The primary end point was the combined outcome of death and reinfarction. BBB was documented in 140 patients (15%). Right BBB (RBBB) was present in 119 patients (13%) and was previous in 27 (23%), persistent in 45 (38%), and transient in 47 (39%). Left BBB (LBBB) was present in 21 patients (2%) and was previous in 8 (38%), persistent in 9 (43%), and transient in 4 (19%). Patients with BBB were older, and more frequently had diabetes, anterior infarctions, a greater Killip class, a lower left ventricular ejection fraction, and greater mortality (all p <0.005) than patients without BBB. The short- and long-term primary outcome occurred more frequently in patients with persistent RBBB/LBBB than in those with previous or transient RBBB/LBBB. On multivariate analysis, persistent RBBB/LBBB emerged as an independent predictor of death and reinfarction. In conclusion, in patients undergoing primary angioplasty in the stent era, BBB is associated with poor short- and long-term prognosis. This risk appears to be particularly high among patients with persistent BBBDepto. de MedicinaFac. de MedicinaTRUEpu