Dataset Information

Optimal Timing of Complete Revascularization in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis.

ABSTRACT:

Background

Studies have suggested that complete revascularization is superior to culprit-only revascularization for the treatment of enzyme-positive acute coronary syndrome. However, the optimal timing of complete revascularization remains unclear. We conducted a systematic review and meta-analysis of randomized controlled trials comparing single-stage complete revascularization with multistage percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction or non-ST-segment elevation myocardial infarction with multivessel disease.

Methods and results

We systematically searched the Cochrane Central Register of Controlled Trials, Embase, PubMed, and MEDLINE for randomized controlled trials comparing single-stage complete revascularization with multistage revascularization in patients with enzyme-positive acute coronary syndrome. The primary outcome was the incidence of major adverse cardiovascular events at longest follow-up. Data were pooled using DerSimonian and Laird random-effects models. Four randomized controlled trials (n=838) were included in our meta-analysis. The risk of unplanned repeat revascularization at longest follow-up was significantly lower in patients randomized to single-stage complete revascularization (risk ratio, 0.68; 95% CI, 0.47-0.99). Results also suggest a trend towards lower risks of major adverse cardiovascular events for patients randomized to single-stage revascularization at 6 months (risk ratio, 0.67; 95% CI, 0.40-1.11) and at longest follow-up (risk ratio, 0.79; 95% CI, 0.52-1.20). Risks of mortality and recurrent myocardial infarction at longest follow-up were also lower with single-stage revascularization, but 95% CIs were wide and included unity.

Conclusions

Our results suggest that single-stage complete revascularization is safe. There also appears to be a trend towards lower long-term risks of mortality and major adverse cardiovascular events; however, additional randomized controlled trials are required to confirm the potential benefits of single-stage multivessel percutaneous coronary intervention.

SUBMITTER: Gaffar R

PROVIDER: S-EPMC5533029 | biostudies-literature | 2017 Apr

REPOSITORIES: biostudies-literature

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Publications

Optimal Timing of Complete Revascularization in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis.

Gaffar Rouan R Habib Bettina B Filion Kristian B KB Reynier Pauline P Eisenberg Mark J MJ

Journal of the American Heart Association 20170410 4

<h4>Background</h4>Studies have suggested that complete revascularization is superior to culprit-only revascularization for the treatment of enzyme-positive acute coronary syndrome. However, the optimal timing of complete revascularization remains unclear. We conducted a systematic review and meta-analysis of randomized controlled trials comparing single-stage complete revascularization with multistage percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction ...[more]

PMID: 28396570

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Project description:OBJECTIVE:Morphine is frequently used in acute coronary syndrome (ACS) due to its analgesic effect, it being recommended in the main cardiology guidelines in Europe and the USA. However, controversy exists regarding its routine use due to potential safety concerns. We conducted a systematic review of randomised-controlled trials (RCTs) and observational studies to synthesise the available evidence. DESIGN:Systematic review and meta-analysis. DATA SOURCES:CENTRAL, MEDLINE, EMBASE and trial registries. ELIGIBILITY CRITERIA FOR SELECTING STUDIES:We included RCTs and observational studies evaluating the impact of morphine in cardiovascular outcomes or platelet reactivity measures. DATA EXTRACTION AND SYNTHESIS:Data were screened, extracted and appraised by two independent reviewers. The data were pooled results using a random-effects model. Outcomes included in-hospital mortality, major adverse cardiovascular events (MACE), platelet reactivity (using VerifyNow) and bleeding, reported as relative risk (RR) with 95% CI. We assessed the confidence in the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We followed the Meta-analysis Of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS:Five RCTs and 12 observational studies were included, enrolling 69 993 participants. Pooled results showed an increased risk of in-hospital mortality (RR 1.45 [95% CI 1.10 to 1.91], low GRADE confidence), MACE (RR 1.21, 95% CI 1.02 to 1.45) and an increased platelet reactivity at 1 and 2 hours (59.37 platelet reactivity units [PRU], 95% CI 36.04 to 82.71; 68.28 PRU, 95% CI 37.01 to 99.55, high GRADE confidence) associated with morphine. We found no significant difference in the risk of bleeding. We found no differences in subgroup analyses based on study design and ACS subtype. CONCLUSIONS:Morphine was associated with an increased risk of in-hospital mortality and MACE but the high risk of bias leads to low result confidence. There is high confidence that morphine decreases the antiplatelet effect of P2Y12 inhibitors. PROSPERO REGISTRATION NUMBER:CRD42016036357.

Project description:Patients with diabetes are at increased risk of acute coronary syndromes (ACS) and their mortality and morbidity outcomes are significantly worse following ACS events, independent of other comorbidities. This systematic review sought to establish the optimum management strategy with focus on P2Y12 blockade in patients with diabetes with ACS.MEDLINE (1946 to present) and EMBASE (1974 to present) databases, abstracts from major cardiology conferences and previously published systematic reviews were searched to June 2014. Relevant randomised control trials with clinical outcomes for P2Y12 inhibitors in adult patients with diabetes with ACS were scrutinised independently by 2 authors with applicable data was extracted for primary composite end point of cardiovascular death, myocardial infarction (MI) and stroke; enabling calculation of relative risks with 95% CI with subsequent direct and indirect comparison.Four studies studied clopidogrel in patients with diabetes, with two (3122 patients) having primary outcome data showing superiority of clopidogrel against placebo with RR0.84 (95% CI 0.72-0.99). Irrespective of management strategy, the newer agents prasugrel (2 studies) and ticagrelor (1 study) had a lower primary event rate compared with clopidogrel; RR 0.80 (95% CI 0.66 to 0.97) and RR 0.89 (95% CI 0.77 to 1.02), respectively. When ticagrelor was indirectly compared with prasugrel, there was a trend to an improved primary outcome with prasugrel (RR 1.11 (95% CI 0.94 to 1.31)) particularly in those managed with percutaneous coronary intervention (PCI) (RR 1.23 (95% CI 0.95 to 1.59)). Prasugrel demonstrated a statistical superiority with prevention of further MI with RR 1.48 (95% CI 1.11 to 1.97). This was not at the expense of increased major thrombolysis in MI (TIMI) bleeding rates RR 0.94 (95% CI 0.59 to 1.51).This meta-analysis shows the addition of a P2Y12 inhibitor is superior to placebo, with a trend favouring the use of prasugrel in patients with diabetes with ACS, particularly those undergoing PCI.

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Dataset Information

Optimal Timing of Complete Revascularization in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis.

Background

Methods and results

Conclusions

Publications

Optimal Timing of Complete Revascularization in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis.

Similar Datasets

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