冠状动脉旁路移植手术患者行远隔缺血预处理的Meta分析

目的系统评价相关的随机对照研究以明确远隔缺血预处理对冠状动脉旁路移植手术患者的心肌保护效果。方法通过电子数据库检索所有对冠状动脉旁路移植手术患者实施远隔缺血预处理的随机对照研究。由两位作者分别提取主要结果指标(术后心肌钙蛋白I水平、术后死亡、术后并发症等)和次要结果指标(术后正性肌力药物使用情况、机械通气时间、ICU停留时间、住院时间等),采用RevMan5.0软件进行Meta分析。结果共纳入7项前瞻性随机对照研究,包括567例患者,其中远隔缺血预处理组281例,对照组286例。与对照组相比,远隔缺血预处理组患者术后心肌钙蛋白I水平降低(P<0.05)。两组患者术后死亡率、并发症发生率、正性肌力药物使用率、术后机械通气时间、ICU停留时间和住院时间差异均无统计学意义(P>0.05)。结论远隔缺血预处理对体外循环下冠状动脉旁路移植手术的患者具有一定的心肌保护效果。     

Effect of Music on Patients Undergoing Colonoscopy: A Meta-Analysis of Randomized Controlled Trials

Purpose Music has been utilized as a therapeutic tool during colonoscopy, but various randomized controlled trials (RCTs) have been inconsistent. We conducted a meta-analysis to analyze the effect of music on patients undergoing colonoscopy. Patients and Methods Multiple medical databases were searched (12/06). Only RCTs on adult subjects that compared music versus no music during colonoscopy were included. Meta-analysis was analyzed for total procedure time, dose of sedative medications (midazolam and mepiridine), and patients’ pain scores, experience, and willingness to repeat the same procedure in the future. Results Eight studies (N = 712) met the inclusion criteria. Patients’ overall experience scores (P < 0.01) were significantly improved with music. No significant differences were noted for patients’ pain scores (P = 0.09), mean doses of midazolam (P = 0.10), mean doses of meperidine (P = 0.23), procedure times (P = 0.06), and willingness to repeat the same procedure in future (P = 0.10). Conclusions Music improves patients’ overall experience with colonoscopy.     

Cardiac Resynchronization Therapy in Patients with Mild Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective  

This review aims at updating the results of cardiac resynchronization therapy (CRT) in mild heart failure patients, and investigating whether CRT can prevent or reverse heart failure progression in an earlier stage.     

Transcatheter Aortic Valve Replacement in Low-Risk Patients: A Meta-Analysis of Randomized Controlled Trials

IntroductionTranscatheter aortic valve replacement (TAVR) has become the standard treatment option for patients with symptomatic severe aortic stenosis (AS) with high surgical risk and a reasonable option for intermediate surgical risk as an alternative to surgical aortic valve replacement (SAVR). The role of TAVR in lower risk patients is less established but has been the focus of recent randomized controlled trials (RCTs). We performed a meta-analysis of RCTs to assess TAVR outcomes among low surgical risk patients.Methods and resultsSystematic search of RCTs was done using PubMed, EMBASE, and Cochrane Library databases. Statistical analysis was performed with RevMan v5.3 software using a random effects model to report risk ratio (RR) with 95% confidence interval (CI). A total of three RCTs including 2698 patients (1375 TAVR and 1323 SAVR) were analyzed. Compared to SAVR, TAVR was not associated with all-cause mortality [RR 0.86 (95% CI 0.61–1.19); P = 0.36; I² = 8%] or stroke [RR 0.82 (0.48–1.43); P = 0.49; I² = 42%]. However, TAVR was significantly associated with lower risk of acute kidney injury [RR 0.27 (0.13–0.54); P = 0.0002; I² = 0%], new-onset atrial fibrillation [RR 0.26 (0.18–0.39); P < 0.00001; I² = 80%], and life-threatening or disabling bleeding [RR 0.35 (0.22–0.55); P < 0.00001; I² = 57%], but a higher risk of moderate-severe paravalvular leak [RR 4.40 (1.22–15.86); P = 0.02; I² = 26%] and permanent pacemaker insertion [RR 2.73 (1.41–5.28); P = 0.003; I² = 83%].ConclusionsThere is no difference in all-cause mortality or stroke between TAVR and SAVR, but TAVR is associated with lower risk of other perioperative complications except for moderate-severe paravalvular leak and the need for permanent pacemaker implantation.     

Drug-Eluting Versus Bare-Metal Stents in Older Patients: A Meta-Analysis of Randomized Controlled Trials

BackgroundDespite the high prevalence of ischemic heart disease in older patients, there is a substantial lack of evidence to guide clinical decision-making in this population. Hence, we performed a meta-analysis to determine the safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus bare-metal stents (BMS).MethodsElectronic databases were searched for randomized trials comparing DES with BMS in patients ≥70 years-old. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included different ischemic and bleeding events. Subgroup analyses for dual-antiplatelet therapy (DAPT) duration were conducted.ResultsWe included 7 trials with a total of 5449 patients. The use of DES compared with BMS was associated with a significant reduction in MACE (odds ratio [OR]:0.76; 95% confidence interval [CI]:0.62–0.93; P = 0.007) with no increased risk of bleeding events (OR: 1.07; 95% CI: 0.89–1.27; P = 0.48). However, longer duration of DAPT (>6 months) for the DES group increased bleeding events (OR: 1.52; 95% CI: 1.05–2.20; P = 0.03). In contrast, shorter DAPT showed persistent efficacy in reducing MACE in DES-treated patients with no increased bleeding events (OR: 0.72; 95% CI: 0.60–0.87; P < 0.01 and OR: 1.01; 95% CI: 0.84–1.22; P = 0.89, respectively).ConclusionsIn older patients who had undergone PCI, DES showed superior efficacy in reducing MACE with no increased risk of bleeding compared with BMS. Persistent MACE reduction was evident with shorter DAPT durations in DES-treated patients.SummaryThis meta-analysis of randomized clinical trials demonstrated that drug-eluting stents were associated with a significant reduction in major adverse cardiovascular events with no increased risk of bleeding compared with bare-metal stents. The risk of bleeding was high with longer dual antiplatelet therapy duration for patients who underwent DES placement. However, short duration of dual antiplatelet therapy substantially reduced major adverse cardiovascular events with no increased bleeding risk.     

Prasugrel vs Ticagrelor for DAPT in Patients with ACS Undergoing PCI: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

IntroductionDual antiplatelet therapy (DAPT) with a P2Y12 inhibitor added to aspirin is considered the standard of care for patients with acute coronary syndrome (ACS) undergoing percutaneous intervention (PCI). Prasugrel and ticagrelor are commonly used P2Y12 inhibitors, and a few head-to-head randomized control trials (RCTs) have been performed. We performed a systematic review and meta-analysis of these RCTs to compare the efficacy and adverse effects between these two agents when used in patients with ACS undergoing PCI.MethodsWe searched PubMed/MEDLINE and Cochrane library for RCTs comparing prasugrel to ticagrelor in ACS. The primary endpoint was major adverse cardiovascular events (MACE). Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), stent thrombosis, major bleeding, and all bleeding event. Estimates were calculated as random effects risk ratios (RRs) with 95% confidence intervals (CI).ResultsSix trials with 6807 patients were included. There were no significant difference of MACE (RR 0.93; 95% CI [0.72–1.20]; p = 0.59; I² = 26%), all-cause mortality (RR 0.92; 95% CI [0.73–1.17]; p = 0.51; I² = 0%), cardiovascular mortality (RR 0.99; 95% CI [0.75–1.31]; p = 0.96; I² = 0%), MI (RR 0.87; 95% CI [0.60–1.27]; p = 0.48; I² = 27%), stent thrombosis (RR 0.64; 95% CI [0.39–1.04]; p = 0.07; I² = 0%), major bleeding (RR 0.94; 95% CI [0.70–1.26]; p = 0.68; I² = 6%), and all bleeding event (RR 0.92; 95% CI [0.77–1.09]; p = 0.32; I² = 0%) for prasugrel compared with ticagrelor.ConclusionThere are no significant difference of MACE, all-cause mortality, cardiovascular mortality, MI, stent thrombosis, and bleeding between prasugrel and ticagrelor when added to aspirin among patients with ACS undergoing PCI.     

Remote Ischemic Preconditioning Reduces Myocardial Injury in Patients Undergoing Coronary Stent Implantation

Background

Myocardial necrosis occurs frequently in elective percutaneous coronary intervention (PCI) and is associated with subsequent major adverse cardiovascular events (MACEs). This study assessed the protective effect of remote ischemic preconditioning (RIPC) in patients undergoing successful drug-eluting stent implantation with normal baseline troponin values.

Methods

We analyzed 205 participants with normal baseline troponin values undergoing successful coronary stent implantation. Subjects were randomized to 2 groups: The RIPC group (n = 101), whose members received RIPC (created by three 5-minute inflations of a pneumatic medical tourniquet cuff to 200 mm Hg around the upper arm, interspersed with 5-minute intervals of reperfusion) < 2 hours before the PCI procedure, and the control group (n = 104).

Results

The primary outcomes were high sensitive cardiac troponin I (hscTnI) levels and incidence of myocardial infarction (MI 4a, defined as hscTnI > 0.20 ng/mL) at 16 hours after the PCI procedure. The median hscTnI at 16 hours after PCI was lower in the RIPC group compared with the unpreconditioned, control group (0.11 vs 0.21 ng/mL; P < 0.01). The incidence of MI 4a was lower in the RIPC group compared with the control group (39% vs 54%, P < 0.05). Index of renal function showed no difference between the 2 groups at 16 hours after PCI (P > 0.05).

Conclusion

RIPC reduced post-PCI TnI release and incidence of MI 4a in patients undergoing elective coronary stent implantation.     

Off-Pump Coronary Artery Bypass Surgery and Acute Kidney Injury: A Meta-Analysis of Randomized Controlled Trials

Background and objectives: Off-pump coronary artery bypass grafting (CABG) has been advocated to cause less inflammation, morbidity, and mortality than the more traditional on-pump technique. This meta-analysis compares these two surgical techniques with respect to causing acute kidney injury (AKI).Design, setting, participants, & measurements: This study searched for randomized controlled trials in MEDLINE and abstracts from the proceedings of scientific meetings through February 2010. Included were trials comparing off-pump to on-pump CABG that reported the incidence of AKI, as defined by a mixture of criteria including biochemical parameter/urine output/dialysis requirement. Mortality was evaluated among the studies that reported kidney-related outcomes. For primary and subgroup analyses, fixed-effect meta-analyses of odds ratios (OR) were performed.Results: In 22 identified trials (4819 patients), the weighted incidence of AKI in the on-pump CABG group was 4.0% (95% confidence interval [CI] 1.8%, 8.5%), dialysis requirement 2.4% (95% CI 1.6%, 3.7%), and mortality 2.6% (95% CI 1.6%, 4.0%). By meta-analysis, off-pump CABG was associated with a 40% lower odds of postoperative AKI (OR 0.60; 95% CI 0.43, 0.84; P = 0.003) and a nonsignificant 33% lower odds for dialysis requirement (OR 0.67; 95% CI 0.40, 1.12; P = 0.12). Within the selected trials, off-pump CABG was not associated with a significant decrease in mortality.Conclusions: Off-pump CABG may be associated with a lower incidence of postoperative AKI but may not affect dialysis requirement, a serious complication of cardiac surgery. However, the different definitions of AKI used in individual trials and methodological concerns preclude definitive conclusions.First introduced in the 1960s (1–3), coronary artery bypass grafting (CABG) remains the standard of care for symptomatic patients with three-vessel or left main coronary artery disease (4,5). For the past 30 years, CABG has been performed primarily with the use of an extracorporeal cardiopulmonary bypass (CPB) machine (on-pump) requiring cannulation of the heart and aorta, crossclamping of the ascending aorta, and the induction of cardioplegic arrest. However, in the 1990s, interest emerged in performing off-pump CABG (6,7) with the hope of reducing postoperative complications associated with the use of CPB, including the generalized systemic inflammatory response (8) and acute organ dysfunction such as cerebral dysfunction (9), myocardial depression (10), and prolonged mechanical ventilation (11).Acute kidney injury (AKI) is a serious complication of on-pump CABG, ranging from small postoperative increases in serum creatinine observed in 5% to 20% of patients (12,13) to severe forms requiring dialysis developing in 1% of patients (14,15). Whether defined by various serum creatinine increments or dialysis requirement, AKI has been linked to excessive in-hospital morbidity and mortality (12,14) and increased resource consumption (16,17). With an estimated 176,000 cardiac bypass procedures performed in 2007 (18), preventing AKI postoperatively is an important goal.Previously published studies comparing the effect of off-pump versus on-pump CABG on kidney end points have yielded conflicting results. Although six meta-analyses have examined this question, results were inconclusive (19,20) or the data synthesis included studies of various designs with a mixture of randomized controlled trials (RCTs) and observational studies (21–24). To shed further light on this question, we conducted a comprehensive meta-analysis restricted to all RCTs published to date, comparing the effect of off-pump versus on-pump CABG on development of AKI including dialysis requirement.     

Remote preconditioning and cardiac surgery: regrouping after Remote Ischemic Preconditioning for Heart Surgery (RIPHeart) and Effect of Remote Ischemic Preconditioning on Clinical Outcomes in Patients Undergoing Coronary Artery Bypass Surgery (ERICCA)

Remote ischaemic preconditioning (RIPC) is an attractive cardioprotective strategy. Although results from animal studies and phase II study on humans are convincing, it cannot have a role in clinical practice until benefits in clinical outcomes are proven in phase III study. Two phase III studies were recently published [Remote Ischemic Preconditioning for Heart Surgery (RIPHeart) and Effect of Remote Ischemic Preconditioning on Clinical Outcomes in Patients Undergoing Coronary Artery Bypass Surgery (ERICCA)] and this article discusses their design, results and implications.     

Selexipag in Patients With Pulmonary Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Despite the availability of treatments for all subgroups of pulmonary hypertension (PH), the prognosis for PH remains poor. This systematic review and meta-analysis aimed to determine the efficacy and safety of selexipag in patients with PH. A systematic search was made of PubMed, Embase, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials (RCTs) on treatment of PH with selexipag, compared with placebo or blank, were reviewed. Studies were pooled to weighted mean differences (WMDs) and risk ratios (RRs), with 95% confidence intervals (CIs). Selexipag was safe and significantly improved hospitalization for worsening of PH, WHO FC, mPAP, NT-proBNP, and cardiac index in patients with PH. Selexipag should be considered in patients with pulmonary arterial hypertension or chronic thromboembolic PH.     

Complete Revascularization in Patients With STEMI and Multi-Vessel Disease: A Meta-Analysis of Randomized Controlled Trials

BackgroundPercutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI). However, efficacy of complete vs culprit only revascularization in patients with STEMI and multivessel disease remains unclear.MethodsWe searched PubMed/MEDLINE, and Cochrane library. The primary endpoint was major adverse cardiovascular events (MACE). Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), repeat revascularization, stroke, major bleeding, and contrast induced nephropathy. Estimates were calculated as random effects hazard ratios (HRs) with 95% confidence intervals (CI).ResultsTwelve trials with 7592 patients were included. There was a significantly lower risk of MACE [HR 0.61; 95% CI (0.43–0.60); p = 0.0009; I² = 72%], cardiovascular mortality [HR 0.74; 95% CI (0.56–0.99); p = 0.04; I² = 2%], and repeat revascularization [HR 0.43; 95% CI (0.31–0.59); p < 0.00001; I² = 67%] in patients treated with complete compared with culprit-only revascularization. There was no statistically significant difference in MI [HR 0.77; 95% CI (0.52–1.12); p = 0.17; I² = 49%], all-cause mortality [HR 0.86; 95% CI (0.65–1.13); p = 0.28; I² = 14%], heart failure [HR 0.82 95% CI (0.51–1.32); p = 0.42; I² = 26%], major bleeding [HR 1.07; 95% CI (0.66–1.75); p = 0.78; I² = 25%], stroke [HR 0.67; 95% CI (0.24–1.89); p = 0.45; I² = 54%], or contrast induced nephropathy, although higher contrast volumes were used in the complete revascularization group [HR 1.22; 95% CI (0.78–1.92); p = 0.39; I² = 0%].ConclusionComplete revascularization was associated with a significantly lower risk of MACE, cardiovascular mortality, and repeat revascularization compared with culprit-only revascularization. These results suggest complete revascularization with PCI following STEMI and multivessel disease should be considered.     

远端缺血预处理在成人瓣膜置换术中的心肌保护作用

目的 评估远端缺血预处理在成人瓣膜置换术中的心肌保护作用.方法 随机选取40例风湿性心脏病需行瓣膜置换术的患者,分为远端预处理组和对照组,每组20例.分别于麻醉诱导前（T0）、停机时（T1）、停机后6小时（T2）和停机后24小时（T3）各时点抽取静脉血,测定血清肌钙蛋白I（cTnI）、乳酸脱氢酶（LDH）、超氧化物歧化酶（SOD）、丙二醛（MDA）、肿瘤坏死因子α（TNF-α）、白介素1β（IL-1β）的浓度.结果 远端预处理组T1、T2、T3的cTnI、LDH、TNF-α、IL-1β浓度均显著低于对照组,差异有统计学意义（P〈0.05）,T2、T3的MDA浓度明显低于对照组,SOD浓度明显高于对照组,差异具有统计学意义（P〈0.05）.结论 远端缺血预处理可减轻心肌缺血再灌注损伤,促进保护性炎性因子的分泌,有助于缺血再灌注后心功能的恢复及改善.     

Quality of Life After Surgery or Surveillance for Asymptomatic Primary Hyperparathyroidism: A Meta-Analysis of Randomized Controlled Trials

A number of studies have investigated the effects of surgery on symptoms and quality of life in patients with hyperparathyroidism. However, the results are inconsistent. We conducted this meta-analysis to quantitatively assess changes in quality of life among patients with asymptomatic primary hyperparathyroidism.Different databases were searched for randomized controlled trials comparing surgery with surveillance. Quality of life was measured by the Short Form-36 general health survey. The pooled random-effects estimates of standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated.Three trials involving 294 participants were included. At 1 year, patients undergoing parathyroidectomy had significantly better physical role functioning (SMD, 0.31; 95% CI 0.04–0.57; P = 0.02) and emotional role functioning (SMD, 0.29; 95% CI 0.02–0.55; P = 0.03). At 2 years, the surgery group had significantly better emotional role functioning (SMD, 0.35; 95% CI 0.02–0.67; P = 0.04) than the surveillance group. Furthermore, compared with baseline, emotional role functioning improved after surgery (SMD, 0.31; 95% CI 0.02–0.60; P = 0.04), whereas emotional role functioning tended to get worse in patients assigned to medical surveillance (SMD, −0.27; 95% CI −0.55 to 0.02; P = 0.07).Although Short Form-36 is a generic instrument, our results suggest that parathyroidectomy may be associated with better quality of life, especially in the emotional aspects of well-being.     

Rosuvastatin Treatment for Preventing Contrast-Induced Acute Kidney Injury After Cardiac Catheterization: A Meta-Analysis of Randomized Controlled Trials

We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the protective effects of rosuvastatin on contrast-induced acute kidney injury (CI-AKI) and major adverse cardiovascular events (MACEs) in patients undergoing cardiac catherization.PubMed, MEDLINE, Web of Science, EMBASE, ClinicalTrials.gov, and the Cochrane Central RCTs were searched for RCTs from inception to May 2015, to compare rosuvastatin for preventing CI-AKI with placebo treatment in patients undergoing cardiac catherization.Five RCTs with a total of 4045 patients involving 2020 patients pretreated with rosuvastatin and 2025 control patients were identified and analyzed. Patients treated with rosuvastatin had a 51% lower risk of CI-AKI compared with the control group based on a fixed-effect model (OR = 0.49, 95% CI = 0.37–0.66, P < 0.001), and showed a trend toward a reduced risk of MACEs (OR = 0.62, 95% CI = 0.36–1.07, P = 0.08). A subgroup analysis showed that studies with Jadad score ≥3 showed a significant reduction of CI-AKI (OR = 0.53, 95% CI, 0.38–0.73, P < 0.001). However, the risk of CI-AKI did not significantly differ in the studies with Jadad score <3 (OR = 0.54, 95% CI, 0.13–2.24, P = 0.40). In addition, the rosuvastatin treatment showed no effect for preventing CI-AKI in patients with chronic kidney disease (CKD) undergoing elective cardiac catherization (I² = 0%, OR = 0.81, 95% CI = 0.41–1.61, P = 0.55).This updated meta-analysis demonstrated that preprocedural rosuvastatin treatment could significantly reduce the incidence of CI-AKI, with a trend toward a reduced risk of MACEs in patients undergoing cardiac catheterization. However, rosuvastatin treatment did not seem to be effective for preventing CI-AKI in CKD patients undergoing elective cardiac catheterization.     

Naltrexone (50 mg) Plus Psychotherapy in Alcohol-Dependent Patients: A Meta-Analysis of Randomized Controlled Trials

Background: Alcoholism is a chronic and potentially fatal disease. One of the therapeutic options is pharmacotherapy with the opioid antagonist naltrexone in combination with psychotherapy, Objectives: The objective of this review was to compare the clinical effectiveness of naltrexone (50 mg/day) versus that of a placebo in alcohol-dependent patients receiving psychotherapy, Methods: The clinical effectiveness of the treatment was assessed in accordance with the principles of systematic review, as outlined in the Cochrane Collaboration guidelines (Cochrane Reviewer’s Handbook) and the guidelines of the Polish Agency for Health Technology Assessment (AHTAPol), Results: Statistical significances in favor of the treatment modality were found in both the percentage of patients maintaining total abstinence and the percentage of relapsed patients, Conclusion: The analysis herein demonstrates that for short (12–16 weeks) period of treatment, a combination of naltrexone administration and psychotherapy results in high clinical efficacy with a safety profile comparable to that of the placebo in the treatment of alcohol-dependent patients. The side effects of naltrexone treatment are usually mild and transient.