Peptides natriurétiques comme facteur pronostique dans l'embolie pulmonaire aigue : une méta-analyse

Introduction –Cette méta-analyse avait pour but d’étudier la valeur pronostique des peptides natriurétiques (PN) isolément ou associée aux troponines dans l’embolie pulmonaire et leur capacité à diagnostiquer une dysfonction ventriculaire droite. Résultats – 23 études ont été incluses (1127 patients). Une élévation des PN était significativement associée avec la mortalité toute cause (OR 6,2), la mortalité spécifique (OR 5,0), et les complications graves (OR 6,7). Parmi les patients avec élévation des PN, une augmentation des troponines était associée avec une évolution défavorable. L’analyse de la valeur des PN dans le diagnostic d’une dysfonction ventriculaire droite était limitée par l’hétérogénéité. Les BNP semblait avoir une meilleure sensibilité et spécificité que les NT-proBNP dans la détection d’une dysfonction ventriculaire droite. Conclusions – Une élévation des PN individualise un sous-groupe de patients à haut risque d’évènements graves. Parmi les patients avec un PN positif, une élévation des troponines constitue un marqueur pronostic indépendant.Background –We performed a meta-analysis to assess the association between elevated natriuretic peptide (PN) levels alone or in conjunction with troponins, and the outcomes (mortality, adverse events, and echographic right ventricular dysfunction) in acute pulmonary embolism (EPA). Results – 23 studies were included (1127 patients). Elevated natriuretic peptide was significantly associated with all-cause mortality (OR 6.2), APE-related mortality (OR 5.0) and serious adverse events (OR 6.7). Among patients with elevated NP levels, increased serum troponins were associated with further increase in risk of adverse outcomes. The analysis of NP accuracy in detecting of right ventricular dysfunction was limited by heterogeneity across studies. BNP appeared to have better sensitivity and specificity than NT-proBNP in detection of right ventricular dysfunction. Conclusions – Elevated NP identified a subset of patients with APE at higher risk of adverse outcomes. Among patients with elevated NP levels, increased troponins were documented as an independent prognostic marker

Consistency of safety and efficacy of new oral anticoagulants across subgroups of patients with atrial fibrillation.

AIMS: The well-known limitations of vitamin K antagonists (VKA) led to development of new oral anticoagulants (NOAC) in non-valvular atrial fibrillation (NVAF). The aim of this meta-analysis was to determine the consistency of treatment effects of NOAC irrespective of age, comorbidities, or prior VKA exposure. METHODS AND RESULTS: All randomized, controlled phase III trials comparing NOAC to VKA up to October 2012 were eligible provided their results (stroke/systemic embolism (SSE) and major bleeding (MB)) were reported according to age (≤ or >75 years), renal function, CHADS2 score, presence of diabetes mellitus or heart failure, prior VKA use or previous cerebrovascular events. Interactions were considered significant at p <0.05. Three studies (50,578 patients) were included, respectively evaluating apixaban, rivaroxaban, and dabigatran versus warfarin. A trend towards interaction with heart failure (p = 0.08) was observed with respect to SSE reduction, this being greater in patients not presenting heart failure (RR = 0.76 [0.67-0.86]) than in those with heart failure (RR = 0.90 [0.78-1.04]); Significant interaction (p = 0.01) with CHADS2 score was observed, NOAC achieving a greater reduction in bleeding risk in patients with a score of 0-1 (RR 0.67 CI 0.57-0.79) than in those with a score ≥2 (RR 0.85 CI 0.74-0.98). Comparison of MB in patients with (RR 0.97 CI 0.79-1.18) and without (RR 0.76 CI 0.65-0.88) diabetes mellitus showed a similar trend (p = 0.06). No other interactions were found. All subgroups derived benefit from NOA in terms of SSE or MB reduction. CONCLUSIONS: NOAC appeared to be more effective and safer than VKA in reducing SSE or MB irrespective of patient comorbidities. Thromboembolism risk, evaluated by CHADS2 score and, to a lesser extent, diabetes mellitus modified the treatment effects of NOAC without complete loss of benefit with respect to MB reduction

Utility of common echocardiographic findings to predict coronary artery lesions in the initial and late phases of Kawasaki disease

LYON1-BU Santé (693882101) / SudocSudocFranceF

When to stop in the quest of formes frustes of connective tissue disease ?

International audienc

A call for evidence in connective tissue diseases-associated interstitial lung disease

International audienc

Nécessité d’améliorer nos connaissances sur les pneumopathies interstitielles diffuses associées aux connectivites

International audienc

Interpreting risk reduction in clinical trials for pulmonary arterial hypertension

Because of scepticism concerning study results when relying solely on relative effect estimates, the number needed to treat (NNT) has been used extensively to quantify the net clinical benefit of an intervention, and is reported increasingly in randomised trials and observational studies. This method is a simple measure representing the number of patients who would need to be treated to prevent one additional adverse event. However, like relative risk, the NNT is an inherently time-dependent measure. Thus, its calculation may lead to misleading interpretations, especially for studies involving varying follow-up times or recurrent outcomes. In addition to study duration and the efficacy of the therapy and the comparator, multiple other factors directly influence the NNT and should be taken into account in its interpretation as for comparative effectiveness of therapies. Its accurate estimation and interpretation, as well as its limitations, are therefore crucial to avoid erroneous clinical and public health decisions. We discuss the calculation and the interpretation of risk reduction and the NNT in the context of the changing landscape of clinical trials in pulmonary arterial hypertension

Consistency of safety profile of new oral anticoagulants in patients with renal failure

International audienceBackgroundThe use of new oral anticoagulants (NOACs) in patients with impaired renal function has raised major concerns, in particular the possibility of an increased risk of bleeding due to accumulation. The aims of this work were to assess the safety of NOACs in patients with renal failure and describe the relationship between clinical events and drug renal excretion magnitude.MethodsAll phase III trials comparing NOACs with vitamin K antagonists (VKAs) in patients with estimated glomerular filtration (eGFR) rate <50mLmin(-1) were eligible. The main safety and efficacy outcomes were major bleeding and thrombosis. A meta-regression was performed to estimate the correlation between the treatment effect estimate and the percentage of renal excretion.ResultsNine studies (12272 patients) were included. A significantly greater relative reduction in major bleeding was seen for NOACs with renal excretion <50% (RR, 0.61; CI, 0.51-0.74) than for those with high renal excretion (RR, 0.96; CI, 0.85-1.07) (interaction test, P<0.0001). A linear relationship between the relative risk of major bleeding and the magnitude of renal excretion was found by meta-regression (R-2=0.66, P=0.03). For thrombosis, a greater treatment effect of NOA vs. INR-adjusted VKA was observed in patients with eGFR <50mLmin(-1) (RR 0.78, CI 0.67-0.92), but no correlation between treatment effect and renal excretion was found.ConclusionsNew oral anticoagulants were at least as effective as VKAs, with reduced risks of major bleeding and thrombosis in patients with eGFR <50mLmin(-1). The renal excretion of these new drugs seemed to modify the safety profile, contrary to the efficacy

Causes and consequences of variation in offspring body mass: meta-analyses in birds and mammals

International audienceEarly survival is highly variable and strongly influences observed population growth rates in most vertebrate populations. One of the major potential drivers of survival variation among juveniles is body mass. Heavy juveniles are better fed and have greater body reserves, and are thus assumed to survive better than light individuals. In spite of this, some studies have failed to detect an influence of body mass on offspring survival, questioning whether offspring body mass does indeed consistently influence juvenile survival, or whether this occurs in particular species/environments. Furthermore, the causes for variation in offspring mass are poorly understood, although maternal mass has often been reported to play a crucial role. To understand why offspring differ in body mass, and how this influences juvenile survival, we performed phylogenetically corrected meta-analyses of both the relationship between offspring body mass and offspring survival in birds and mammals and the relationship between maternal mass and offspring mass in mammals. We found strong support for an overall positive effect of offspring body mass on survival, with a more pronounced influence in mammals than in birds. An increase of one standard deviation of body mass increased the odds of offspring survival by 71% in mammals and by 44% in birds. A cost of being too fat in birds in terms of flight performance might explain why body mass is a less reliable predictor of offspring survival in birds. We then looked for moderators explaining the among-study differences reported in the intensity of this relationship. Surprisingly, sex did not influence the intensity of the offspring mass-survival relationship and phylogeny only accounted for a small proportion of observed variation in the intensity of that relationship. Among the potential factors that might affect the relationship between mass and survival in juveniles, only environmental conditions was influential in mammals. Offspring survival was most strongly influenced by body mass in captive populations and wild populations in the absence of predation. We also found support for the expected positive effect of maternal mass on offspring mass in mammals (r pearson = 0.387). As body mass is a strong predictor of early survival, we expected heavier mothers to allocate more to their offspring, leading them to be heavier and so to have a higher survival. However, none of the potential factors we tested for variation in the maternal mass-offspring mass relationship had a detectable influence. Further studies should focus on linking these two relationships to determine whether a strong effect of offspring size on early survival is associated with a high correlation coefficient between maternal mass and offspring mass