Antibiotics for vascular diseases: a meta-analysis of randomized controlled trials

BACKGROUND: Trials of antibiotic treatment of vascular diseases, in attempts to eradicate possible microbial initiators, have had mixed results. We sought to evaluate the efficacy of antibiotics in treating patients with atherosclerotic vascular diseases, using a meta-analysis. METHODS: We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials and also used cross-references. Randomized controlled trials of antibiotic treatment of vascular diseases were included. Two independent raters assessed the trials for quality. We performed summary estimates, subgroup analyses and tests for homogeneity. RESULTS: Twelve trials, with a total of 12,236 patients, were included. Antibiotic treatment resulted in a non-significant reduction in the risk of new vascular events or death (odds ratio (OR), 0.84; 95% confidence interval (CI), 0.67-1.05). There was significant heterogeneity between the sub-groups in type of vascular disease (coronary heart disease, CHD versus non-CHD (p=0.01)). Among the 72 non-CHD patients, a trend appears for treatment benefit in reducing recurrent events or death (OR, 0.22; 95% CI, 0.07-0.66). CONCLUSIONS: Overall, antibiotic treatment did not significantly reduce occurrence of new vascular events or death. However, further trials are needed to confirm the benefit demonstrated in non-CHD patients.     

Cardiac morphology for the millennial cardiology fellow: Nomenclature and advances in morphologic imaging

Cardiology fellows‐in‐training, both in adult and pediatric hospitals, need structured education in regards to congenital heart disease (CHD) nomenclature. With improved survival of patients with CHD, it is not uncommon for these patients to seek care in multiple adult and pediatric hospitals. A deep understanding of CHD nomenclature would aid in providing accurate medical and surgical care for these patients. In this forum, we share our experience with such structured education and also comment on recent advances in morphologic imaging that would aid in understanding the nomenclature.     

Comparative Stroke,Bleeding, and Mortality Risks in Older Medicare Patients Treated with Oral Anticoagulants for Nonvalvular Atrial Fibrillation

BackgroundNonvitamin K antagonist oral anticoagulants (NOACs) are alternatives to warfarin in patients with nonvalvular atrial fibrillation. Randomized trials compared NOACs with warfarin, but none have compared individual NOACs against each other for safety and effectiveness.MethodsWe performed a retrospective new-user cohort study of patients with nonvalvular atrial fibrillation enrolled in US Medicare who initiated warfarin (n = 183,318), or a standard dose of dabigatran (150 mg twice daily; n = 86,198), rivaroxaban (20 mg once daily; n = 106,389), or apixaban (5 mg twice daily; n = 73,039) between October 2010 and September 2015. Propensity score-adjusted Cox proportional hazards regression was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the outcomes of thromboembolic stroke, intracranial hemorrhage, major extracranial bleeding, and all-cause mortality, comparing each NOAC with warfarin, and with each other NOAC.ResultsCompared with warfarin, each NOAC was associated with reduced risks of thromboembolic stroke (20%-29% reduction; P = .002 [dabigatran], P < 0.001 [rivaroxaban, apixaban]), intracranial hemorrhage (35%-62% reduction; P < 0.001 [each NOAC]), and mortality (19%-34% reduction; P < .001 [each NOAC]). The NOACs were similar for thromboembolic stroke but rivaroxaban was associated with increased risks of intracranial hemorrhage (vs dabigatran: HR = 1.71; 95% CI, 1.35-2.17), major extracranial bleeding (vs dabigatran: HR = 1.32; 95% CI, 1.21-1.45; vs apixaban: HR = 2.70; 95% CI, 2.38-3.05), and death (vs dabigatran: HR = 1.12; 95% CI, 1.01-1.24; vs apixaban: HR = 1.23; 95% CI, 1.09-1.38). Dabigatran was associated with reduced risk of intracranial hemorrhage (HR = 0.70; 95% CI ,0.53-0.94) and increased risk of major extracranial bleeding (HR = 2.04; 95% CI, 1.78-2.32) compared with apixaban.ConclusionsAmong patients treated with standard-dose NOAC for nonvalvular atrial fibrillation and warfarin users with similar baseline characteristics, dabigatran, rivaroxaban, and apixaban were associated with a more favorable benefit–harm profile than warfarin. Among NOAC users, dabigatran and apixaban were associated with a more favorable benefit–harm profile than rivaroxaban.