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2. Safety and efficacy of thrombectomy in patients undergoing primary percutaneous coronary intervention for Acute ST elevation MI: A Meta-Analysis of Randomized Controlled Trials

Author

Grossman P Michael, Hameed Irfan, Chetcuti Stanley, Tamhane Umesh U, Moscucci Mauro, and Gurm Hitinder S

Subjects
Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Abstract Background Clinical trials comparing thrombectomy devices with conventional percutaneous coronary interventions (PCI) in patients with acute ST elevation myocardial infarction (STEMI) have produced conflicting results. The objective of our study was to systematically evaluate currently available data comparing thrombectomy followed by PCI with conventional PCI alone in patients with acute STEMI. Methods Seventeen randomized trials (n = 3,909 patients) of thrombectomy versus PCI were included in this meta-analysis. We calculated the summary odds ratios for mortality, stroke, post procedural myocardial blush grade (MBG), thrombolysis in myocardial infarction (TIMI) grade flow, and post procedural ST segment resolution (STR) using random-effects and fixed-effects models. Results There was no difference in risk of 30-day mortality (44/1914 vs. 50/1907, OR 0.84, 95% CI 0.54-1.29, P = 0.42) among patients randomized to thrombectomy, compared with conventional PCI. Thrombectomy was associated with a significantly greater likelihood of TIMI 3 flow (1616/1826 vs. 1533/1806, OR 1.41, P = 0.007), MBG 3 (730/1526 vs. 486/1513, OR 2.42, P < 0.001), STR (923/1500 vs. 715/1494, OR 2.30, P < 0.001), and with a higher risk of stroke (14/1403 vs. 3/1413, OR 2.88, 95% CI 1.06-7.85, P = 0.04). Outcomes differed significantly between different device classes with a trend towards lower mortality with manual aspiration thrombectomy (MAT) (21/949 vs.36/953, OR 0.59, 95% CI 0.35-1.01, P = 0.05), whereas mechanical devices showed a trend towards higher mortality (20/416 vs.10/418, OR 2.07, 95% CI 0.95-4.48, P = 0.07). Conclusions Thrombectomy devices appear to improve markers of myocardial perfusion in patients undergoing primary PCI, with no difference in overall 30-day mortality but an increased likelihood of stroke. The clinical benefits of thrombectomy appear to be influenced by the device type with a trend towards survival benefit with MAT and worsening outcome with mechanical devices.

Published
2010
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3. Receipt of Cardiac Medications Upon Discharge Among Men and Women With Acute Coronary Syndrome and Nonobstructive Coronary Artery Disease

Author

Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan ; Division of Cardiovascular Medicine University of Michigan Health System 24 Frank Lloyd Wright Drive Ann Arbor, Michigan 48106., Department of Medicine, Section of Cardiology, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Lebanon, New Hampshire, Ramanath, Vijay S., Armstrong, David F., Grzybowski, Mary, Rahnama-Mohagdam, Sahand, Tamhane, Umesh U., Gordon, Kelly, Froehlich, James B., Eagle, Kim A., Jackson, Elizabeth A., Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan ; Division of Cardiovascular Medicine University of Michigan Health System 24 Frank Lloyd Wright Drive Ann Arbor, Michigan 48106., Department of Medicine, Section of Cardiology, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Lebanon, New Hampshire, Ramanath, Vijay S., Armstrong, David F., Grzybowski, Mary, Rahnama-Mohagdam, Sahand, Tamhane, Umesh U., Gordon, Kelly, Froehlich, James B., Eagle, Kim A., and Jackson, Elizabeth A.

Abstract

Background Management of acute coronary syndrome (ACS) patients with nonobstructive epicardial coronary artery disease (CAD) remains poorly understood. Hypothesis Acute coronary syndrome patients with nonobstructive CAD are less likely to receive effective cardiac medications upon discharge from the hospital. Methods We identified patients hospitalized with ACS that underwent coronary angiography and had a 6-month follow-up. Patients were grouped by CAD severity: nonobstructive CAD (<50% blockage in all vessels) or obstructive CAD (???50% blockage in ??? 1 vessels). Data were collected on demographics, medications at discharge, and adverse outcomes at 6 months, for all patients. Results Of the 2264 ACS patients included in the study: 123 patients had nonobstructive CAD and 2141 had obstructive CAD. Cardiac risk factors including hypertension and diabetes were common among patients with nonobstructive CAD. Men and women with nonobstructive CAD were less likely to receive cardiac medications compared to patients with obstructive CAD including aspirin (87.8% vs 95.0%, P = 0.001), ??-blockers (74.0% vs 89.2%, P < 0.001), or statins (69.1% vs 81.2%, P = 0.001). No gender-related differences in discharge medications were observed for patients with nonobstructive CAD. However, women with nonobstructive CAD had similar rates of cardiac-related rehospitalization as men with obstructive CAD (23.3% and 25.9%, respectively). Conclusions Patients with nonobstructive CAD are less likely to receive evidence-based medications compared to patients with obstructive CAD, despite the presence of CAD risk factors and occurrence of an ACS event. Further research is warranted to determine if receipt of effective cardiac medications among patients with nonobstructive CAD would reduce cardiac-related events. Copyright ?? 2010 Wiley Periodicals, Inc.

Published
2010

9. Safety and efficacy of thrombectomy in patientsundergoing primary percutaneous coronaryintervention for Acute ST elevation MI: AMeta-Analysis of Randomized Controlled Trials.

Author

Tamhane, Umesh U., Chetcuti, Stanley, Hameed, Irfan, Grossman, P. Michael, Moscucci, Mauro, and Gurm, Hitinder S.

Subjects
PERCUTANEOUS cholecystostomy, MYOCARDIAL infarction, RANDOMIZED controlled trials, CORONARY disease, META-analysis
Abstract

Background: Clinical trials comparing thrombectomy devices with conventional percutaneous coronary interventions (PCI) in patients with acute ST elevation myocardial infarction (STEMI) have produced conflicting results. The objective of our study was to systematically evaluate currently available data comparing thrombectomy followed by PCI with conventional PCI alone in patients with acute STEMI. Methods: Seventeen randomized trials (n = 3,909 patients) of thrombectomy versus PCI were included in this meta-analysis. We calculated the summary odds ratios for mortality, stroke, post procedural myocardial blush grade (MBG), thrombolysis in myocardial infarction (TIMI) grade flow, and post procedural ST segment resolution (STR) using random-effects and fixed-effects models. Results: There was no difference in risk of 30-day mortality (44/1914 vs. 50/1907, OR 0.84, 95% CI 0.54-1.29, P = 0.42) among patients randomized to thrombectomy, compared with conventional PCI. Thrombectomy was associated with a significantly greater likelihood of TIMI 3 flow (1616/1826 vs. 1533/1806, OR 1.41, P = 0.007), MBG 3 (730/1526 vs. 486/1513, OR 2.42, P < 0.001), STR (923/1500 vs. 715/1494, OR 2.30, P < 0.001), and with a higher risk of stroke (14/1403 vs. 3/1413, OR 2.88, 95% CI 1.06-7.85, P = 0.04). Outcomes differed significantly between different device classes with a trend towards lower mortality with manual aspiration thrombectomy (MAT) (21/949 vs.36/953, OR 0.59, 95% CI 0.35-1.01, P = 0.05), whereas mechanical devices showed a trend towards higher mortality (20/416 vs.10/418, OR 2.07, 95% CI 0.95-4.48, P = 0.07). Conclusions: Thrombectomy devices appear to improve markers of myocardial perfusion in patients undergoing primary PCI, with no difference in overall 30-day mortality but an increased likelihood of stroke. The clinical benefits of thrombectomy appear to be influenced by the device type with a trend towards survival benefit with MAT and worsening outcome with mechanical devices. [ABSTRACT FROM AUTHOR]

Published
2010
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10. The Relative Renal Safety of Iodixanol Compared With Low-Osmolar Contrast Media A Meta-Analysis of Randomized Controlled Trials

Author

Reed, Michael, Meier, Pascal, Tamhane, Umesh U., Welch, Kathy B., Moscucci, Mauro, and Gurm, Hitinder S.

Subjects
meta-analysis, iodixanol, contrast-induced acute kidney injury, contrast-induced nephropathy, contrast media, low-osmolar contrast media
Abstract

ObjectivesWe sought to compare the nephrotoxicity of the iso-osmolar contrast medium, iodixanol, to low-osmolar contrast media (LOCM).BackgroundContrast-induced acute kidney injury (CI-AKI) is a common cause of in-hospital renal failure. A prior meta-analysis suggested that iodixanol (Visipaque, GE Healthcare, Princeton, New Jersey) was associated with less CI-AKI than LOCM, but this study was limited by ascertainment bias and did not include the most recent randomized controlled trials.MethodsWe searched Medline, Embase, ISI Web of Knowledge, Google Scholar, Current Contents, and International Pharmaceutical Abstracts databases, and the Cochrane Central Register of Controlled Trials from 1980 to November 30, 2008, for randomized controlled trials that compared the incidence of CI-AKI with either iodixanol or LOCM. Random-effects models were used to calculate summary risk ratios (RR) for CI-AKI, need for hemodialysis, and death.ResultsA total of 16 trials including 2,763 subjects were pooled. There was no significant difference in the incidence of CI-AKI in the iodixanol group than in the LOCM group overall (summary RR: 0.79, 95% confidence interval [CI]: 0.56 to 1.12, p = 0.19). There was no significant difference in the rates of post-procedure hemodialysis or death. There was a reduction in CI-AKI when iodixanol was compared with ioxaglate (RR: 0.58, 95% CI: 0.37 to 0.92; p = 0.022) and iohexol (RR: 0.19, 95% CI: 0.07 to 0.56; p = 0.002), but no difference when compared with iopamidol (RR: 1.20, 95% CI: 0.66 to 2.18; p = 0.55), iopromide (RR: 0.93, 95% CI: 0.47 to 1.85; p = 0.84), or ioversol (RR: 0.92, 95% CI: 0.60 to 1.39; p = 0.68).ConclusionsThis meta-analysis including 2,763 subjects suggests that iodixanol, when compared with LOCM overall, is not associated with less CI-AKI. The relative renal safety of LOCM compared with iodixanol may vary based on the specific type of LOCM.

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