Trends, Predictors and Outcomes After Utilization of Targeted Temperature Management in Cardiac Arrest Patients With Anoxic Brain Injury

BackgroundTargeted Temperature Management (TTM) is a class I recommendation for the management of sudden cardiac arrest (SCA) patients with presumed brain injury. We aimed to study trends, predictors and outcomes in SCA patients from a nationally represented US population sample.MethodsWe utilized the National Inpatient Sample from years 2005 to 2014 for the purpose of our study. Patients with SCA and anoxic brain injury were selected using relevant ICD-9 codes. Data were analyzed for trends over the years and key outcomes were assessed. Logistic regression analysis was done to determine predictors of TTM utilization in our study population.ResultsA total of 78,465 patients with SCA and anoxic brain injury were identified from January 2005 to December 2014. Out of these, approximately 4,481 (5.7%) patients underwent TTM. Patients that underwent TTM were younger compared to patients without TTM utilization (60.67 vs. 63.27 years, P < 0.01). African Americans, Hispanics and women were less likely to undergo TTM. Myocardial infarction, electrolyte disorders and cardiogenic shock were associated with higher odds of TTM utilization. Sepsis, renal failure and diabetes were associated with underutilization of TTM. Inpatient mortality was higher in patients who did not undergo TTM when compared to patients who underwent TTM (67.30% vs. 65.10%, P < 0.01).ConclusionsAlthough TTM utilization increased over our study period, the overall application of TTM was still dismal. Factors that circumvent TTM utilization need to be addressed in future studies so more eligible patients could benefit from this life saving therapy

Association of lowering apolipoprotein B with cardiovascular outcomes across various lipid-lowering therapies: Systematic review and meta-analysis of trials

AimsThe effect of therapeutic lowering of apolipoprotein B (apoB) on mortality and major adverse cardiovascular events is uncertain. It is also unclear whether these potential effects vary by different lipid-lowering strategies.MethodsA total of 29 randomized controlled trials were selected using PubMed, Cochrane Library and EMBASE through 2018. We selected trials of therapies which ultimately clear apolipoprotein B particles by upregulating low-density lipoprotein receptor (LDL-R) expression (statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, bile acid sequestrants) or therapies which reduce apolipoprotein B independent of LDL-R (cholesteryl ester transfer protein inhibitor, fibrates, niacin, omega-3 fatty acids) with sample size of ≥1000 patients and follow-up of ≥1 year. The meta-regression and meta-analyses were constructed using a random effects model.ResultsIn 332,912 patients, meta-regression analyses showed relative risks of 0.95 for all-cause mortality (95% confidence interval 0.92–0.99) and 0.93 (0.88–0.98) for cardiovascular mortality for every 10 mg/dL decrease in apolipoprotein B by all interventions combined. Reduction in all-cause mortality was limited to statins (0.92 (0.86–0.98)). For MACE, the relative risk per 10 mg/dL reduction in apolipoprotein B was 0.93 (0.90–0.97) for all therapies combined, with both statin (0.88 (0.83–0.93)) and non-statin therapies (0.96 (0.94–0.99)). which clear apolipoprotein B by upregulating LDL-R showing significant reductions; whereas interventions which lower apolipoprotein B independent of LDL-R did not demonstrate this effect (1.02 (0.81–1.30)).ConclusionWhile both statin and established non-statin therapies (PCSK9 inhibitor and ezetimibe) reduced cardiovascular risk per decrease in apolipoprotein B, interventions which reduce apolipoprotein B independently of LDL-R were not associated with cardiovascular benefit

Meta- Analysis of Lowering Apolipoprotein B With Mortality and Cardiovascular Outcomes Across Various Lipid Lowering Therapies

Introduction: Apolipoprotein B (apoB) concentration is reflective of the total burden of atherogenic lipoprotein particles, including low-density lipoprotein (LDL).Hypothesis: Association between apoB lowering and cardiovascular (CV) outcomes might vary across different classes of lipid-lowering therapies.Methods: Data bases of PubMed, Cochrane and EMBASE were searched through 2018 to select randomized controlled trials of lipid lowering therapies which reduce apoB by upregulating LDL receptor (LDL-R) expression (ezetimibe, PCSK9 inhibitors, bile acid sequestrants) or interventions which reduce apoB independent of LDL-R (CETP inhibitor, fibrates, niacin, n-3 fatty acids), with sample size ≥1000 patients and follow-up of ≥1 yr. The meta-regression and meta-analyses were constructed using a random effects model. The primary and secondary outcomes were all-cause mortality and major adverse CV events (MACE), respectively.Results: In 29 trials (332,912 patients), meta-regression showed relative risks (RR) of 0.95 for all-cause mortality (95% CI 0.92-0.99; Figure) and 0.93 (0.88-0.98) for CV mortality per 10 mg/dL decrease in apoB by all interventions combined. Reduction in all-cause mortality was only found for statins (0.92 [0.86-0.98]). For MACE, the RR per 10 mg/dL reduction in apoB was 0.93 (0.90-0.97) for all therapies combined, but varied by type of therapies; with both statin (0.88 [0.83-0.93]) and non-statin therapies (0.96 [0.94-0.99]) which clear apoB by upregulating LDL-R showing significant reductions; whereas, interventions which lower apoB independent of LDL-R did not demonstrate this effect (1.02 [0.81-1.30]).Conclusions: Reduction in apoB resulted in mortality and CV risk reduction. While both statin and established non-statin therapies (PCSK9 inhibitor and ezetimibe) reduced CV risk per decrease in apoB, interventions which reduce apoB independent of LDL-R were not associated with CV benefit