Search

The optimal therapy for submassive pulmonary embolism (sPE), defined by right ventricular dysfunction without hemodynamic instability, is uncertain. We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus systemic anticoagulation (SA) alone in patients with sPE. We searched PubMed, EMBASE, Cochrane, ClinicalTrials.gov, and Google Scholar (from inception through May 2022) for studies comparing outcomes of CDT versus SA in sPE. Studies were identified, and data were extracted by 2 independent reviewers. We used a random-effects model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 90-day, and 1-year mortality, major and minor bleeding, and need for blood transfusion. A total of 12 studies (1 randomized, 11 observational) with 9,789 patients were included. Compared with SA, CDT was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, plt;0.00001), 30-day mortality (RR 0.37, 95% CI 0.18 to 0.73, p = 0.004), 90-day mortality (RR 0.36, 95% CI 0.17 to 0.72, p = 0.004), and a tendency toward lower 1-year mortality (RR 0.56, 95% CI 0.29 to 1.05, p = 0.07). The risks of major bleeding (RR 1.31, 95% CI 0.57 to 3.01, p = 0.53), minor bleeding (RR 1.67, 95% CI 0.77 to 3.63, p = 0.20), and the rates of blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08) were similar between the 2 strategies. In conclusion, in patients with sPE, CDT is associated with significantly lower in-hospital, 30-day, and 90-day mortality and a tendency toward lower 1-year mortality with similar bleeding rates compared with SA. This study expands the evidence supporting CDT as first-line therapy for sPE, and randomized controlled trials are indicated to confirm our findings.

Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) optimize percutaneous coronary intervention (PCI) by characterizing lesion morphology, accurately measuring vessel dimensions, and optimizing stent characteristics. We sought to compare the utilization of OCT and IVUS to guide inpatient PCI and their relative association with in-hospital mortality and readmission rates. We queried the National Readmission Database to identify patients undergoing intracoronary imaging-guided PCI from 2010 to 2019 and compared outcomes and readmission rates between patients undergoing OCT-guided PCI and IVUS-guided PCI. Multivariable logistic regression was performed to generate adjusted odds ratios (aOR) of adverse outcomes between the 2 groups. Of 3,71,450 intracoronary imaging-guided PCI admissions, OCT (n = 12,808) was used less frequently than IVUS (n = 358,642). The use of OCT-guided PCI increased from 0.1% in 2010 to 0.6% in 2019 while the rate of IVUS-guided PCI increased from 7.2% in 2010 to 9.4% in 2019 (both ptrend0.001). Patients undergoing OCT compared to IVUS had lower in-hospital mortality (aOR 0.69, P = 0.015) and 30-day readmission rate (aOR 0.91, P = 0.040) with no statistical difference in 90-day readmission rate (aOR 0.93, P = 0.065). Heart failure was the most common cause of 30-day and 90-day readmissions in both cohorts. There was no difference in the rate of acute kidney injury between the 2 modalities. In this in-patient admission database of intracoronary imaging-guided PCI, OCT-guided PCI during index hospitalization appears to be associated with lower in-hospital mortality and 30-day readmission rates compared to IVUS-guided PCI with no difference in terms of the 90-day readmission rates.

To assess readmission rates in nonagenarians (age ≥ 90 years) with ST-elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (pPCI) versus no pPCI.There are limited data exploring readmissions following STEMI in nonagenarians undergoing pPCI versus no pPCI.We retrospectively analyzed the Nationwide Readmissions Database to identify nonagenarians hospitalized with STEMI. We divided the cohort into two groups based on pPCI status. We compared mortality during index hospitalization and during 30-day readmission, readmission rates, and causes of readmissions.We identified 58,231 nonagenarian STEMI hospitalizations between 2010 and 2018, of which 18,809 (32.3%) included pPCI, and 39,422 (67.7%) had no pPCI. Unadjusted unplanned 30-day readmission was higher in pPCI cohort (21.0% vs. 15.4%, p 0.001). However, mortality during index hospitalization and during 30-day readmission were significantly lower in pPCI cohort (15.8% vs. 32.2%, p 0.001; 7.4% vs. 14.2%, p 0.001, respectively). After adjusting for baseline characteristics, hospitalizations that included pPCI had 25% greater odds of unplanned 30-day readmission (adjusted odds ratio [aOR]: 1.25, 95% confidence interval [CI]: 1.12-1.39, p 0.001) and 49% lower odds of in-hospital mortality during index hospitalization (aOR: 0.51, 95% CI: 0.46-0.56, p 0.001). Heart failure was the most common cause of readmission in both cohorts followed by myocardial infarction.In nonagenarians with STEMI, pPCI is associated with slightly higher 30-day readmission but significantly lower mortality during index hospitalization and during 30-day readmission than no pPCI. Given the overwhelming mortality benefit with pPCI, further research is necessary to optimize the utilization of pPCI while reducing readmissions following STEMI in nonagenarians.

While aortic valve replacement (AVR) is indicated for symptomatic severe aortic stenosis (AS), the appropriate management of asymptomatic severe AS remains unclear. We conducted an updated meta-analysis to compare the outcomes of surgical AVR (SAVR) versus conservative treatment in patients with asymptomatic severe AS.We searched PubMed, EMBASE, Cochrane, clinicaltrials.gov, and Google Scholar for studies comparing outcomes of SAVR versus conservative treatment in asymptomatic severe AS. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each individual study. Outcomes included all-cause mortality, cardiovascular and non-cardiovascular mortality, 30-day operative mortality, sudden cardiac death (SCD), heart failure hospitalization (HFH), myocardial infarction (MI), and stroke.A total of 8 studies with 2685 patients were included. The mean age was above 60 years, and the median follow-up duration was 4 years. Compared to conservative treatment, SAVR was associated with significantly lower all-cause mortality (RR 0.39; 95% CI 0.23-0.64) and HFH rates (RR 0.18; 95% CI 0.05-0.71). There were no significant differences in cardiovascular mortality (RR 0.24; 95% CI 0.03-1.67), non-cardiovascular mortality (RR 0.49; 95% CI 0.23-1.03), 30-day operative mortality (RR 0.48; 95% CI 0.10-2.32), SCD (RR 0.37; 95% CI 0.05-2.89), MI (RR 0.48; 95% CI 0.04-5.52), and stroke rates (RR 1.20; 95% CI 0.35-4.11) between the two strategies.In patients with asymptomatic severe AS, SAVR is associated with significantly lower all-cause mortality and HFH compared to conservative treatment. While SAVR is a promising option for asymptomatic severe AS, most studies were observational and nonrandomized; randomized trials are needed to establish a clear benefit.

Chemotherapeutic regimens have cardiotoxic properties and thorax irradiation is associated with accelerated coronary artery disease (CAD). There is limited data regarding the influence of cancer on outcomes after percutaneous coronary intervention (PCI), as cancer patients were not routinely included in the PCI trials. We performed a systematic review and meta-analysis to compare the early outcomes of PCI between patients with active/historical cancer and patients without a cancer history. A systematic search was made in the PubMed, Medline, and Cochrane databases using the search terms "PCI" and "Cancer". The major outcomes were in-hospital mortality, in-hospital cardiovascular mortality, 30-day mortality, and peri-procedural complications. We used random effects model to aggregate data and calculate pooled incidence and risk ratios with 95% confidence intervals (CIs). A total of 7 studies were included, out of which 4 studies reported in-hospital mortality. Compared to patients without cancer, patients with active/historical cancer undergoing PCI had higher rates of in-hospital mortality (relative risk [RR] 1.89; 95% CI 1.33-2.70; P = 0.0004), in-hospital cardiovascular mortality (RR 2.21; 95% CI 1.19-4.08; P = 0.01), 30-day mortality (RR 2.01; 95% CI 1.24-3.27; P = 0.005), and peri-procedural blood transfusion (RR 1.73; 95% CI 1.02-2.95; P = 0.04). There were no significant differences in peri-procedural myocardial re-infarction, new-onset heart failure, shock, and stroke between the two cohorts. In conclusion, Among patients undergoing PCI, active/historical cancer was associated with worse early mortality compared to patients without a history of cancer. Management of cancer patients undergoing PCI should be individualized and involve multi-specialist team discussion to narrow the mortality gap.