Thromboembolic risk and effect of oral anticoagulation according to atrial fibrillation patterns: A systematic review and meta‐analysis

Oral anticoagulation (OAC ) is recommended in both paroxysmal atrial fibrillation (pxAF ) and nonparoxysmal AF (non‐pxAF ), but disagreement exists in classes of recommendation. Data on incidence/rate of stroke in pxAF are conflicting, and OAC is often underused in this population. The objectives of the meta‐analysis were to investigate different impact on outcomes of pxAF and non‐pxAF , with and without OAC . Two reviewers searched for prospective studies on risk of stroke and systemic embolism (SE ) in pxAF and non‐pxAF , with and without OAC . Quality of evidence was assessed according to GRADE approach. Stroke combined with SE was the main outcome. Meta‐regression was performed to evaluate OAC effect on stroke and SE incidence rate. We identified 18 studies. For a total of 239 528 patient‐years of follow‐up. The incidence rate of stroke/SE was 1.6% (95% confidence interval [CI ]: 1.3%‐2.0%) in pxAF and 2.3% (95% CI : 2.0%‐2.7%) in non‐pxAF . Paroxysmal AF was associated with a lower risk of overall thromboembolic (TE ) events (risk ratio: 0.72, 95% CI : 0.65‐0.80, P < 0.00001) compared with non‐pxAF . In both groups, the annual rate of TE events decreased as proportion of patients treated with OAC increased. Non‐pxAF showed a reduction from 3.7% to 1.7% and pxAF from 2.5% to 1.2%. Major bleeding rates did not differ among groups. Stroke/SE risk is significantly lower, although clinically meaningful, in pxAF . OAC consistently reduces TE event rates across any AF pattern. As a whole, these data provide the evidence to warrant OAC irrespective of the AF pattern in most (virtually all) patients.     

Impact of antioxidant supplementations on cardio‐renal protection in cardiac surgery: an updated and comprehensive meta‐analysis and systematic review

This systematic review with meta‐analysis sought to determine the strength of evidence in terms of the impact of common antioxidant supplementations, such as N‐acetylcysteine (NAC), vitamin C, and polyunsaturated fatty acids (PUFA) on perioperative outcomes after cardiac surgery with particular focus on the incidence of atrial fibrillation (AF) and acute kidney injury (AKI) with associated mortality. A total of 29 trials were identified that reported incidence of AF and 17 trials that reported incidence of AKI. Pooled analysis reported that NAC (OR=0.5; P=.001), vitamin C (OR=0.4; P=.001), and PUFA (OR=0.8; P=.01) administration were associated with significantly reduced incidence of AF. In terms of postoperative AKI, only NAC was shown to be a beneficial supplement that was able to significantly reduce the incidence of AKI (OR=0.7; P=.01), and NAC could also significantly decrease overall mortality (OR=0.3; P=.03) following cardiac surgery. The use of NAC in patients undergoing cardiac surgery should be strongly recommended due to its combined cardio‐renal protective effects and reduced mortality. Also, PUFA and vitamin C might be able to significantly decrease the incidence of arrhythmia; however, reno‐protective effects and impact on overall mortality of these supplements seem to be less impressive.     

Polyunsaturated fatty acids for the prevention of atrial fibrillation after cardiac surgery: An updated meta-analysis of randomized controlled trials

BackgroundSeveral clinical trials showed inconsistent results of the effect of polyunsaturated fatty acids (PUFA) on the incidence of post-operative atrial fibrillation (POAF). The aim of this meta-analysis is to investigate the effect of PUFA on the incidence of POAF in patients undergoing cardiac surgery.Methods and resultsPUBMED, EMBASE, Cochrane Library, and Google Scholar databases were searched for randomized controlled trials. Statistical heterogeneity was assessed using I² statistic and Cochran's Q statistic. The effect of PUFA on the incidence of POAF was presented as risk ratio (RR) with 95% confidence intervals (CIs) using a fixed effect model or random effect model depending on statistical heterogeneity. Subgroup analyses were conducted based on the baseline characteristics of patients, types of surgery, the ratio of eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA), and the quality of the studies. Eight trials with 2687 patients were included in the analysis. Treatment with PUFA had no effect on the incidence of POAF in patients undergoing cardiac surgery compared to placebo [RR 0.86; 95% CI 0.71–1.04, p = 0.110]. Subgroup analyses showed the quality of the studies, the ratio of EPA/DHA, accompanied with diabetes might impact the effect of PUFA on POAF. No evidence of publication bias was detected.ConclusionsThe present analysis suggests that treatment with PUFA preoperatively has no effect on the incidence of POAF in patients undergoing open heart surgery. However, patients with diabetes might get benefits from the treatment with PUFA preoperatively.     

Diastolic function and new-onset atrial fibrillation following cardiac surgery

Background:

Numerous studies have reported predictors of new-onset postoperative atrial fibrillation (POAF) following cardiac surgery, which is associated with increased length of stay, cost of care, morbidity, and mortality. The purpose of this study was to examine the association between preoperative diastolic function and occurrence of new-onset POAF in patients undergoing a variety of cardiac surgeries at a single institution.

Methods:

Using data from a prospective study from November 2007 to January 2010, a retrospective review was conducted. The diastolic function of each patient was determined from preoperative transthoracic echocardiograms. Occurrence of new-onset POAF was prospectively noted for each patient in the original study. Demographic and operative characteristics of the study population were analyzed to determine predictors of POAF.

Results:

Of 223 patients, 91 (40.8%) experienced new-onset POAF. Univariate predictors of POAF included increasing age, male gender, operations involving mitral valve repair/replacement, nonsmoking, hypertension, increased intraoperative pulmonary artery pressure, grade I diastolic dysfunction, abnormal diastolic function of any grade, decreased medial e’, elevated medial E/e’, and increased left atrial volume. Multivariate predictors of POAF included increasing age, increased left atrial volume, and elevated initial intraoperative pulmonary artery pressure. Even after exclusion of patients with hypertrophic obstructive cardiomyopathy or those undergoing mitral valve operations, diastolic dysfunction was not a multivariate predictor of POAF.

Conclusions:

In the patient population studied here, preoperative diastolic dysfunction was not predictive of POAF. In addition to increasing age, initial intraoperative pulmonary artery systolic pressure and left atrial volume were both significant multivariate predictors of POAF.     

Associations between adipokines and atrial fibrillation: A systematic review and meta-analysis

AimsAlthough overweight and obesity are associated with increased risk of atrial fibrillation (AF), the underlying mechanisms are not well characterised. Recent data suggest that this link may be partly due to abnormal adipose tissue-derived cytokines or adipokines. However, this relationship is not well clarified. To evaluate the association between adipokines and AF in a systematic review and meta-analysis.Data synthesisPubMed, Embase, and Web of Science Core Collection were searched from inception through 1^st March 2021. Studies were included if they reported any adipokine and AF, with their quality assessed using the Newcastle-Ottawa scale. Data were independently abstracted, with unadjusted and multivariable adjusted estimates pooled in a random-effects meta-analysis. Data are presented for overall prevalent or incident AF and AF subtypes (paroxysmal, persistent, or non-paroxysmal AF). A total of 34 studies, with 31,479 patients, were included. The following adipokines were significantly associated with AF in the pooled univariate data — apelin (risk ratio for prevalent AF: 0.05 [0.00–0.50], p = 0.01; recurrent AF: 0.21 [0.11–0.42], p < 0.01) and resistin (incident AF: 2.05 [1.02–4.1], p = 0.04; prevalent AF: 2.62 [1.78–3.85], p < 0.01). Pooled analysis of multivariable adjusted effect size estimates showed adiponectin as the sole independent predictor of AF incidence (1.14 [1.02–1.27], p = 0.02). Moreover, adiponectin was associated with non-paroxysmal AF (persistent AF: 1.45 [1.08–1.94, p = 0.01; non-paroxysmal versus paroxysmal AF: 3.14 [1.87–5.27, p < 0.01).ConclusionsAdipokines, principally adiponectin, apelin, and resistin, are associated with the risk of atrial fibrillation. However, the association is not seen after multivariate adjustment, likely reflecting the lack of statistical power. Future research should investigate these relationships in larger prospective cohorts and how they can refine AF monitoring strategies.PROSPERO IDCRD42020208879.     

Vitamin D supplementation and body weight status: a systematic review and meta‐analysis of randomized controlled trials

Vitamin D is anticipated to have many extra‐skeletal health benefits. We questioned whether supplementation with the vitamin influenced body weight and composition. A systematic review and meta‐analysis was conducted on high‐quality, randomized controlled trials (RCTs) that had supplemented vitamin D without imposing any caloric restriction. Eighteen trials reporting either body weight, body mass index (BMI), fat mass (FM), percentage fat mass (%FM) or lean body mass (LBM) met our criteria. Twelve studies provided the required data for the meta‐analysis. Vitamin D supplementation did not influence the standardized mean difference (SMD) for body weight, FM, %FM or LBM. A small but non‐significant decrease in BMI (SMD = ?0.097, 95% confidence interval: [?0.210, 0.016], P = 0.092) was observed. Meta‐regression confirmed that neither the absolute vitamin D status achieved nor its change from baseline influenced the SMD of any obesity measure. However, increasing age of the subjects predicted a shift in the SMD for FM towards the placebo treatment, whereas a greater percentage of women in these studies favoured a decrease in FM following vitamin D. Vitamin D supplementation did not decrease measures of adiposity in the absence of caloric restriction. A potential confounding by age and gender was encountered.     

Vitamin C and COVID-19 treatment: A systematic review and meta-analysis of randomized controlled trials

Background and aimsVitamin C has been used as an anti-oxidant in various diseases including viral illnesses like coronavirus disease (COVID-19).MethodsMeta-analysis of randomized controlled trials (RCT) investigating the role of vitamin C supplementation in COVID-19 was carried out.ResultsTotal 6 RCTs including n = 572 patients were included. Vitamin C treatment didn't reduce mortality (RR 0.73, 95% CI 0.42 to 1.27; I² = 0%; P = 0.27), ICU length of stay [SMD 0.29, 95% CI -0.05 to 0.63; I² = 0%; P = 0.09), hospital length of stay (SMD -0.23, 95% CI -1.04 to 0.58; I² = 92%; P = 0.57) and need for invasive mechanical ventilation (Risk Ratio 0.93, 95% CI 0.61 to 1.44; I² = 0%; P = 0.76). Further sub-group analysis based on severity of illness (severe vs. non-severe), route of administration (IV vs. oral) and dose (high vs. low) failed to show any observable benefits.ConclusionNo significant benefit noted with vitamin C administration in COVID-19. Well-designed RCTs with standardized control group needed on this aspect.     

Bariatric surgery: a systematic review and network meta‐analysis of randomized trials

The clinical efficacy and safety of bariatric surgery trials were systematically reviewed. MEDLINE, EMBASE, CENTRAL were searched to February 2009. A basic PubCrawler alert was run until March 2010. Trial registries, HTA websites and systematic reviews were searched. Manufacturers were contacted. Randomized trials comparing bariatric surgeries and/or standard care were selected. Evidence‐based items potentially indicating risk of bias were assessed. Network meta‐analysis was performed using Bayesian techniques. Of 1838 citations, 31 RCTs involving 2619 patients (mean age 30–48 y; mean BMI levels 42–58 kg/m²) met eligibility criteria. As compared with standard care, differences in BMI levels from baseline at year 1 (15 trials; 1103 participants) were as follows: jejunoileal bypass [MD: ?11.4 kg/m²], mini‐gastric bypass [?11.3 kg/m²], biliopancreatic diversion [?11.2 kg/m²], sleeve gastrectomy [?10.1 kg/m²], Roux‐en‐Y gastric bypass [?9.0 kg/m²], horizontal gastroplasty [?5.0 kg/m²], vertical banded gastroplasty [?6.4 kg/m²], and adjustable gastric banding [?2.4 kg/m²]. Bariatric surgery appears efficacious compared to standard care in reducing BMI. Weight losses are greatest with diversionary procedures, intermediate with diversionary/restrictive procedures, and lowest with those that are purely restrictive. Compared with Roux‐en‐Y gastric bypass, adjustable gastric banding has lower weight loss efficacy, but also leads to fewer serious adverse effects.     

Post‐operative behavioural management in bariatric surgery: a systematic review and meta‐analysis of randomized controlled trials

Recent research has provided evidence that bariatric surgery maximizes long‐term weight loss in patients with severe obesity. However, a substantial number of patients experience poor weight loss outcome and weight regain over time. Post‐operative behavioural management may facilitate long‐term weight control in bariatric surgery population. The objective of this systematic review and meta‐analysis was to determine the effects of post‐operative behavioural management on weight loss following bariatric surgery. Eligible articles were systematically searched in electronic databases. Among the 414 citations, five randomized controlled trials, two prospective and eight retrospective cohort trials analysing behavioural lifestyle interventions and support groups fulfilled the inclusion criteria. The main finding is that behavioural management had a positive effect on weight loss following surgery. In 13 studies, patients receiving behavioural management had greater weight loss than patients receiving usual care or no treatment. A meta‐analysis of five randomized controlled trials suggests greater weight loss in patients with behavioural lifestyle interventions compared with control groups. Post‐operative behavioural management has the potential to facilitate optimal weight loss following bariatric surgery, but conclusions were limited by the small and heterogeneous samples of studies. A more rigorous empirical evaluation on its clinical significance is warranted to improve effectiveness of bariatric surgery.     

Preemptive versus prophylactic protocol to prevent cytomegalovirus infection after renal transplantation: a meta‐analysis and systematic review of randomized controlled trials

L.‐F. Zhang, Y.‐T. Wang, J.‐H. Tian, K.‐H. Yang, J.‐Q. Wang. Preemptive versus prophylactic protocol to prevent cytomegalovirus infection after renal transplantation: a meta‐analysis and systematic review of randomized controlled trials.
Transpl Infect Dis 2011: 13: 622–632. All rights reserved Objective. This review was conducted to assess the efficacy of preemptive versus prophylactic protocols for the prevention and treatment of cytomegalovirus (CMV) infection and disease after renal transplantation. Methods. PubMed, EMBASE, the Cochrane Library, SCI, the China Journal Full‐text Database, the Chinese Biomedical Database, the Chinese Scientific Journals Full‐text Database, and the CMA Digital Periodicals were searched to collect randomized controlled trials (RCTs) of preemptive versus prophylactic protocols for the prevention and treatment of CMV infections after renal transplantation (up to April 2010). Two reviewers independently extracted data using a designed extraction form. The quality of the included trials was evaluated according to the Cochrane Handbook. RevMan 5.0 software was used for data analysis. Results. Seven RCTs, involving 560 patients, were included. The results of the meta‐analysis were as follows: the prophylactic protocol was significantly more effective than the preemptive protocol in reducing CMV infections and the recurrence rates of CMV infection; both the preemptive protocol and the prophylactic protocol reduced the risk of CMV disease, with no significant differences; no significant differences were observed in the risks of mortality, acute rejection, graft loss, other infections, or neutropenia between preemptive therapy and prophylaxis. Conclusion. Preemptive protocols are as effective as prophylaxis in reducing the risk of CMV disease in renal transplant recipients, whereas the prophylactic protocols could more effectively reduce the CMV recurrence rates. However, the trial data were very sparse, so further observations of the long‐term effects of the protocols are needed.     

Effect of antioxidant vitamin supplementation on endothelial function in type 2 diabetes mellitus: a systematic review and meta‐analysis of randomized controlled trials

Controversy exists among trials assessing whether prolonged antioxidant vitamin supplementation improves endothelial function in type 2 diabetes mellitus (T2DM) subjects. The aim of this study was to systematically review and quantify the effect of antioxidant vitamin supplementation on endothelial function in T2DM subjects. MEDLINE, Cochrane, Scopus and Web of Science were searched up to February 2013 for randomized controlled trials assessing the effect of antioxidant vitamin E and/or C supplementation on endothelial function in T2DM subjects. Ten randomized controlled trials comparing antioxidant vitamin‐supplemented and control groups (overall n = 296) met the inclusion criteria. Post‐intervention standardized mean difference (SMD) in endothelial function did not reach statistical significance between groups (0.35; 95% confidence interval = ?0.17, 0.88; P = 0.18). In subgroup analysis, post‐intervention endothelial function was significantly improved by antioxidant vitamin supplementation in T2DM subgroups with body mass index (BMI) ≤ 29.45 kg m^?2 (SMD = 1.02; P < 0.05), but not in T2DM subgroups with BMI > 29.45 kg m^?2 (SMD = ?0.07; P = 0.70). In meta‐regression, an inverse association was found between BMI and post‐intervention SMD in endothelial function (B = ?0.024, P = 0.02). Prolonged antioxidant vitamin E and/or C supplementation could be effective to improve endothelial function in non‐obese T2DM subjects.