Safety of short-term dual antiplatelet therapy after drug-eluting stents:An updated meta-analysis with direct and adjusted indirect comparison of randomized control trials

Background: Duration of dual antiplatelet therapy (DAPT) following drug-eluting stents (DES) remains controversial and is a topic of ongoing research. Methods: Direct and adjusted indirect comparisons of all the recent randomized control trials (RCTs) were performed to evaluate the safety of short-term versus long-term DAPT following DES. Results: 8 RCTs were identified and 7 (16,318 subjects) were included. 4 groups of 3 vs 12 months, 6 vs 12 months, 6 vs 24 months and 12 vs 24 months of DAPT were used for direct comparison. There was no significant difference in stent thrombosis, myocardial infarction (MI), stroke and revascularization, cardiovascular and all-cause mortality between the different durations in all 4 groups. Pooling trials of 3–6 months of DAPT against 12 months, we found a significant reduction in the risk of total bleeding (RR 0.61, 95% CI 0.43–0.87). Adjusted indirect comparison between 3 vs 6 months, 3 vs 24 months and 6 vs 24 month duration of DAPT showed no significant differences in risk of death or MI, or revascularization between 3 or 6 months and 24 months. However, 24 months of DAPT was associated with significantly more bleeding than 3 or 6 months. Conclusions: 3 to 6 months of DAPT following second generation DES and above is safe with no increased risk of thrombotic complications and mortality, and lower bleeding risk. However a tailored approach may be more appropriate for high-risk patients. Keywords: Percutaneous coronary intervention; Drug-eluting stent; Acute coronary syndrome; Dual antiplatelet treatment; Duration of therap

Risk prediction models for mortality in community-acquired pneumonia : a systematic review

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Efficacy of antiplatelet therapy in secondary prevention following lacunar stroke:Pooled analysis of randomized trials

Background and Purpose: Lacunar stroke accounts for ≈25% of ischemic stroke, but optimal antiplatelet regimen to prevent stroke recurrence remains unclear. We aimed to evaluate the efficacy of antiplatelet agents in secondary stroke prevention after a lacunar stroke. Methods: We searched MEDLINE, Embase, and the Cochrane library for randomized controlled trials that reported risk of recurrent stroke or death with antiplatelet therapy in patients with lacunar stroke. We used random effects meta-analysis and evaluated heterogeneity with I2. Results: We included 17 trials with 42 234 participants (mean age 64.4 years, 65% male) and follow up ranging from 4 weeks to 3.5 years. Compared with placebo, any single antiplatelet agent was associated with a significant reduction in recurrence of any stroke (risk ratio [RR] 0.77, 0.62–0.97, 2 studies) and ischemic stroke (RR 0.48, 0.30–0.78, 2 studies), but not for the composite outcome of any stroke, myocardial infarction, or death (RR 0.89, 0.75–1.05, 2 studies). When other antiplatelet agents (ticlodipine, cilostazol, and dipyridamole) were compared with aspirin, there was no consistent reduction in stroke recurrence (RR 0.91, 0.75–1.10, 3 studies). Dual antiplatelet therapy did not confer clear benefit over monotherapy (any stroke RR 0.83, 0.68–1.00, 3 studies; ischemic stroke RR 0.80, 0.62–1.02, 3 studies; composite outcome RR 0.90, 0.80–1.02, 3 studies). Conclusions: Our results suggest that any of the single antiplatelet agents compared with placebo in the included trials is adequate for secondary stroke prevention after lacunar stroke. Dual antiplatelet therapy should not be used for long-term stroke prevention in this stroke subtype

Effect of age on the prognostic value of left ventricular function in patients with acute coronary syndrome:a prospective registry study

Objective: This study aims to study the prognostic impact of LV function on mortality and examine the effect of age on the prognostic value of left ventricular function.  Methods: We examined the Myocardial Ischaemia National Audit Project (MINAP) registry (2006-2010) data with a mean follow up of 2.1 years. LV function was categorized into good (ejection fraction (EF) ≥50%), moderate (EF 30-49%) and poor (EF <30%) categories. Cox-proportional hazards models were constructed to examine the prognostic significance of LV function in different age groups (<65, 65-74, 75-84 and ≥85 years) on all-cause mortality adjusting for baseline variables.  Results: Of 424,848 patients, LV function data available for 123,609. Multiple imputations were used to impute missing values of LV function and the final sample for analyses were drawn from 414,305. After controlling for confounders, 339,887 participants were included in the regression models. For any age group, mortality was higher with worsening degree of LV impairment. Increased age reduced the adverse prognosis associated with reduced LV function (hazard ratios (HRs) of death comparing poor LV function to good LV function were 2.11 95%CI 1.88-2.37 for age <65 years and 1.28 95%CI 1.20-1.36 for age ≥85 years. Older patients had a high mortality risk even in those with good LV function. HRs of mortality for ≥85 compared to <65 years (HR=1.00) within good, moderate and poor ejection fractions groups were 5.89, 4.86 and 3.43, respectively.  Conclusions: In patients with ACS, clinicians should interpret the prognostic value of LV function taking into account patient’s age

Should Audits Consider the Care Pathway Model? : A New Approach to benchmarking Real-World Activities

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Gastrointestinal bleeding in chronic kidney disease patients: a systematic review and meta-analysis

Abstract Gastrointestinal bleeding (GIB) is a major cause of mortality in patients with renal failure. We conducted a systematic review of the literature to evaluate the rates, predictors, and outcomes of GIB in patients with chronic kidney disease (CKD). A search of MEDLINE and EMBASE databases was performed, and data were extracted from relevant studies. Statistical pooling was performed to determine the rate of GIB in patients with CKD, and a random-effect meta-analysis was performed to determine the predictors of GIB and mortality in patients with GIB. Twenty-two studies were included in this review, with 7,810,273 patients with CKD included in the analysis. The pooled results of five studies suggested that the rate of GIB in patients with CKD was 2.2%, and among the studies in which patients with CKD underwent endoscopy, the pooled results for GIB were 35.8%. Receipt of dialysis (OR 14.48, 95%CI 4.96–42.32), older age (OR 1.03, 95%CI 1.02–1.05), diabetes mellitus (OR 1.30, 95%CI 1.22–1.39), history of ulcers (OR 1.53, 95%CI 1.03–2.26), and cirrhosis (OR 1.73, 95%CI 1.41–2.12) were significantly associated with GIB. The pooled results suggest a twofold increase in the odds of mortality with GIB, with significant heterogeneity (OR 2.12, 95%CI 1.45–3.10, I2 = 93%). GIB in patients with CKD affects 2% of patients but can be greater in the group of patients who underwent endoscopy. Receipt of dialysis is a strong predictor of GIB, and sustained GIB is associated with a twofold increase in the odds of mortality compared to patients without GIB. Key points The rate of gastrointestinal bleeding (GIB) in patients with chronic kidney disease (CKD) was 2.2%. The rate of GIB in patients with CKD is higher in those who undergo endoscopy. Dialysis, older age, diabetes mellitus, history of ulcers, and cirrhosis were significantly associated with GIB in CKD. GIB in patients with CKD was associated with a twofold increase in the odds of mortality

Bariatric surgery and its impact on cardiovascular disease and mortality : A systematic review and meta-analysis

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Pre-eclampsia is associated with a twofold increase in diabetes : a systematic review and meta-analysis

CSK and RH are funded by National Institute for Health Research Academic Clinical Fellowships. This study was supported by a grant from the North Staffs Heart Committee.Peer reviewedPublisher PD

Misdiagnosis of pulmonary embolism and missed pulmonary embolism: A systematic review of the literature

Pulmonary embolism (PE) is a common and life-threatening condition. Misdiagnosis of PE is not uncommon as symptoms can overlap with other diagnoses and could cause potential harm. We conducted a systematic review to estimate rates of misdiagnosis and factors may be associated with misdiagnosis of PE. We searched MEDLINE and EMBASE for studies that evaluated the misdiagnosis of PE. The rate of misdiagnosis was pooled and results were narratively synthesized. A total of 18 studies were included which included 2,053 patients with a diagnosis of PE. Two different definitions were used for misdiagnosis of PE. The first refers to an initial diagnosis that is not PE and the patient is found to have PE. The second definition refers to patients who do not have a diagnosis of PE while they were alive and PE was subsequently found on autopsy. The pooled results across the studies suggest that in ED settings 27.5% of patients with PE are misdiagnosed initially and half of all patients in inpatient settings are misdiagnosed (53.6%). Among patients that die in intensive care who undergo autopsy 37.9% were found to have PE that was missed. The commonly diagnosed conditions instead of PE were respiratory infection, heart failure and acute coronary syndrome (ACS). Misdiagnosis in patients with an eventual diagnosis of PE is common. Clinicians should consider PE as differential diagnosis in patients who are initially suspected to have chest infection, heart failure or ACS who have negative diagnostic tests or poor response to treatment

Marital status and risk of cardiovascular diseases : A systematic review and meta-analysis

Acknowledgement We acknowledge the ASPIRE Summer Studentship programme at Keele University for the support of this work. Funding This work is supported by the ASPIRE Summer Studentship programme at Keele University.Peer reviewedPostprin