The association between P2Y12 receptor inhibitors reloading and in-hospital outcomes in non-ST-segment elevation acute coronary syndrome (NSTEACS) patients who were on chronic P2Y12 receptor inhibitors therapy remained underdetermined.The Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS project) is a national registry active from November 2014 to December 2019. 4790 NSTEACS patients on chronic P2Y12 receptor inhibitors therapy were included. Cox proportional hazard models, Kaplan-Meier curves, and subgroup analyses were conducted.The NSTEACS patients who received reloading of P2Y12 receptor inhibitors were younger and had fewer comorbid conditions. The reloading group had a lower risk of major adverse cardiac events (MACE) (0.51% vs. 1.43%, P = 0.007), and all-cause death (0.36% vs. 0.99%, P = 0.028), the risks of myocardial infarction and major bleeding were not significantly different between patients with and without reloading. In survival analysis, a lower cumulative risk of MACE could be identified (Log-rank test, P = 0.007) in reloading group. In the unadjusted Cox model, reloading P2Y12 receptor inhibitors was associated with a decreased risk of MACE [HR, 0.35; 95% CI 0.16-0.78; (P = 0.010)] and all-cause death [HR, 0.37; 95% CI 0.14-0.94; (P = 0.036)]. Reloading of P2Y12 receptor inhibitors was associated with a decreased risk of MACE in most of the subgroups.In NSTEACS patients already taking P2Y12 receptor inhibitors, we observed a decreased risk of in-hospital MACEs and all-cause mortality and did not observe an increased risk of major bleeding, with reloading. The differential profile in the two groups might influence this association and further studies are warranted.https://www.gov (Unique identifier: NCT02306616, date of first registration: 03/12/2014).
Abstract Background The patients with return of spontaneous circulation post cardiac arrest have a mortality rate of up to 30-50%. Hemodynamic support is a key component of out-of-hospital cardiac arrest (OHCA) management and is essential to ensure survival. The meta-analysis was performed to investigate the optimizing blood pressure targets in survivors of OHCA. Methods Studies were searched in electronic databases from January 1, 2015 to January 13, 2023. Results were pooled using random effects model and fixed effects model and are presented as odd ratios (ORs) with 95% confidence intervals (CI). The primary outcome was all-cause death and the secondary outcome were severe bleeding, arrhythmia, renal replacement therapy, cerebral performance category (CPC) score≥3, modified Rankin Scale (mRS) score≥4 and the level of serum norepinephrine, neuron-specific enolase (NSE), troponin T.This study was registered with INPLASY 2022120065. Results Four studies involving 1,327 participants were included. No significant differences of the risk of all-cause death were found between the low-target blood pressure and high-target blood pressure strategy (OR 0.93 [95% CI 0.73–1.17], I²=0%, P=0.55). Meanwhile, the low-target blood pressure therapy had a higher proportion of mRS score≥4 (OR 0.43 [95% CI 0.20–0.94], I²=0%, P=0.03) ≥4 compared with the high-target blood pressure therapy. No significant between-group differences were identified among patients in the level of the serum NSE (SD 0.82 [95% CI -1.50–3.13], I²=28%, P=0.49), troponin T (SD 0.54 [95% CI -0.03–1.12], I²=0%, P=0.07), renal replacement therapy (OR 1.09 [95% CI 0.71–1.69], I²=49%, P=0.69), severe bleeding(OR 1.18 [95% CI 0.85–1.65], I²=0%, P=0.33) and arrhythmia(OR 0.84 [95% CI 0.57–1.24], I²=0%, P=0.38). Conclusions The higher mean arterial pressure (MAP) is not associated with improved outcome when compared to conventional target, but may be associated with worse neurological outcome.
Objectives: Meta-analysis was performed to evaluate the effect of staged revascularization with concomitant chronic total occlusion (CTO) in the non-infarct-associated artery (non-IRA) in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (p-PCI). Methods: Various electronic databases were searched for studies published from inception to June, 2021. The primary endpoint was all-cause death, and the secondary endpoint was a composite of major adverse cardiac events (MACEs). Odds ratios (ORs) were pooled with 95% confidence intervals (CIs) for dichotomous data. Results: Seven studies involving 1540 participants were included in the final analysis. Pooled analyses revealed that patients with successful staged revascularization for CTO in non-IRA with STEMI treated with p-PCI had overall lower all-cause death compared with the occluded CTO group (OR, 0.46; 95% CI, 0.23–0.95), cardiac death (OR, 0.43; 95% CI, 0.20–0.91), MACEs (OR, 0.47; 95% CI, 0.32–0.69) and heart failure (OR, 0.57; 95% CI, 0.37–0.89) compared with the occluded CTO group. No significant differences were observed between groups regarding myocardial infarction and repeated revascularization. Conclusions: Successful revascularization of CTO in the non-IRA was associated with better outcomes in patients with STEMI treated with p-PCI.
BACKGROUND: Whether it is effective and safe to extend the time window of intravenous thrombolysis up to 24 hours after the last known well is unknown. We aimed to determine the efficacy and safety of tenecteplase in Chinese patients with acute ischemic stroke due to large/medium vessel occlusion within an extended time window. METHODS: Patients with ischemic stroke presenting 4.5 to 24 hours from the last known well, with a favorable penumbral profile and an associated large/medium vessel occlusion, were randomized 1:1 to either 0.25 mg/kg tenecteplase or the best medical treatment. A favorable penumbral profile was defined as a hypoperfusion lesion volume to infarct core volume ratio >1.2, with an absolute volume difference >10 mL, and an ischemic core volume <70 mL. The primary outcome was the achievement of major reperfusion without symptomatic intracranial hemorrhage within 24 to 48 hours post-randomization. Major reperfusion was defined as the restoration of blood flow of >50% of the involved ischemic territory. Secondary outcomes included recanalization, infarct growth, major neurological improvements, change in the National Institutes of Health Stroke Scale score, hemorrhagic transformation within 24 to 48 hours, systemic bleeding at discharge, and modified Rankin Scale (score 0–1, score 0–2, score 5–6, and modified Rankin Scale distribution) at 90 days. The comparison of the primary outcome between groups was conducted using modified Poisson regression with a log-link function and robust error variance, adjusted for time from the last known well to randomization, the site of vessel occlusion, and planned endovascular treatment. RESULTS: Among 224 enrolled patients, 111 were assigned to receive tenecteplase and 113 to receive the best medical treatment (including 23% [n=26] of participants who received intravenous tissue-type plasminogen activator). The mean (SD) age of the tenecteplase group and the best medical treatment group was 64.2 (10.4) and 63.6 (11.0) years old, with 72.1% (n=80) and 70.8% (n=80) male enrolled, respectively. A proportion of 54.9% (n=123) of patients were transferred to the catheter room for preplanned endovascular treatment. The primary outcome occurred in 33.3% (n=37) of the tenecteplase group versus 10.8% (n=12) in the best medical treatment group (adjusted relative risk, 3.0 [95% CI, 1.6–5.7]; P =0.001). Tenecteplase significantly increased the recanalization rate compared with the best medical treatment (35.8% [n=39] versus 14.3% [n=16], adjusted relative risk, 2.5 [95% CI, 1.4–4.4]; P =0.002). There were no significant differences in clinical efficacy outcomes or rates of hemorrhagic transformation between the groups. CONCLUSIONS: Administered at a dose of 0.25 mg/kg intravenously, tenecteplase increased reperfusion without symptomatic intracranial hemorrhage in patients with ischemic stroke selected by imaging in late-time window treatment but did not change clinical outcomes at 90 days. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04516993.
Review question / Objective: We sought to conduct a systematic review and metaanalysis to evaluate the optimizing blood pressure targets in survivors of cardiac arrest.Condition being studied: All cause death, s e v e re b l e e d i n g , a r r h y t h m i a , re n a l replacement therapy, CPC score ≥3, mRS s c o r e ≥ 4 , t h e l e v e l o f s e r u m norepinephrine, neuron-specific enolase and troponin T.
ObjectiveHalf of the patients with acute large artery occlusion (LAO) have poor outcomes after endovascular treatment (EVT). Early complications such as cerebral edema and symptomatic intracranial hemorrhage (sICH) can lead to early neurological deterioration (END), which correlates with hemodynamics. This study aimed to identify the hemodynamic predictors of END and outcomes in LAO patients after EVT.MethodsA total of 76 patients with anterior circulation LAO who underwent EVT and received transcranial Doppler (TCD) monitoring were included. Bilateral middle cerebral artery (MCA) blood flow velocities (BFVs) were measured repeatedly within 1 week. Mean flow velocities (MFV) and MFV index (ipsilateral MFV/contralateral MFV) were calculated. The primary outcome was the incidence of END within 72 h. The secondary outcome was the functional outcome at 90 days—a good outcome was defined as a modified Rankin scale (mRS) score of 0∼2, while a poor outcome was defined as an mRS score of 3∼6.ResultsA total of 13 patients (17.1 %) experienced END within 72 h, including 5 (38.5 %) with cerebral edema, 5 (38.5 %) with sICH, and 3 (23.0 %) with infarct progression. Multivariable logistic regression analysis showed that a higher 24 h MFV index was independently associated with END (aOR 10.5; 95 % CI 2.28–48.30, p = 0.003) and a poor 90-day outcome (aOR 5.10; 95 % CI 1.38–18.78, p = 0.014). The area under the receiver operating characteristic (ROC) curve (AUC) of the 24 h MFV index for predicting END was 0.807 (95 % CI 0.700–0.915, p = 0.0005), the sensitivity was 84.6 %, and the specificity was 66.7 %. At the 1-week TCD follow-up, patients who had poor 90-day outcomes showed significantly higher 1-week iMFV [73.5 (58.4–99.0) vs. 57.7 (45.3–76.3), p = 0.004] and MFV index [1.24 (0.98–1.57) vs.1.0 (0.87–1.15) p = 0.007]. A persistent high MFV index (PHMI) was independently associated with a poor outcome (aOR 7.77, 95 % CI 1.81–33.3, p = 0.06).ConclusionTCD monitoring within 24 h after EVT in LAO patients can help predict END, while dynamic follow-up within 1 week is valuable in determining ineffective recanalization.
Abstract Objectives Heart failure with mildly reduced ejection fraction (HFmrEF) or heart failure with preserved ejection fraction (HFpEF) are associated with significant morbidity and mortality, as well as growing health and economic burden. Sodium-glucose co-transporter 2 (SGLT2) inhibitors are very promising for the outcome improvement of patients with HFpEF or HFmrEF. The meta-analysis was performed to investigate the effects of SGLT2 inhibitors in HFpEF or HFmrEF, by pooling data from all clinically randomized controlled trials (RCTs) available to increase power to testify. Methods Studies were searched in electronic databases from inception to November, 2022. We performed a meta-analysis to estimate the effect of SGLT2 inhibitors on clinical endpoints in patients with HFpEF or HFmrEF, using trial-level data with consistent endpoint definitions. The primary outcome was the composite of heart failure (HF) hospitalization or cardiovascular death. Hazard ratio (HR) was pooled with 95% confidence interval (CI) for dichotomous data. This study was registered with INPLASY 2022110095. Results Six studies involving 15,989 participants were included into the final analysis. Pooled analyses revealed that SGLT2 inhibitors significantly reduced the composite of HF hospitalization or cardiovascular death [HR: 0.79 (0.72–0.85); I 2 = 0%; P < 0.00001] and HF hospitalizations [HR: 0.74 (0.67–0.82); I 2 = 0%; P < 0.00001]. This finding was seen in both HFmrEF trials [HR: 0.76 (0.67–0.87); I 2 = 49%; P < 0.0001] and HFpEF subgroup studies [HR: 0.70 (0.53–0.93); I 2 = 0%; P = 0.01]. The incidence of any serious adverse events [OR: 0.89 (0.83–0.96); I 2 = 0%; P = 0.002] was significantly lower in the SGLT2 inhibitor arm. No significant differences were observed between the two groups with regard to cardiovascular death and all-cause death. Conclusions This meta-analysis of patients with heart failure of left ventricular ejection fraction (LVEF) > 40% showed that SGLT2 inhibitors significantly reduce the risk of the composite of cardiovascular death and hospitalization for heart failure, but not cardiovascular death and all-cause death. Nevertheless, given that SGLT2 inhibitors may reduce the risk of hospitalization for heart failure, they should be considered the fundamental treatment for all patients with HFpEF or HFmrEF.
Additive manufacturing (AM) is an efficient method to fabricate components with complex geometries. However, high levels of tensile residual stress generated in the near-surface layer of the fabricated components due to the high cooling rate and large thermal gradients during the AM process have limited their applications. Laser shock processing (LSP) is a novel surface-strengthening technique applied to modify the near-surface of metallic materials with the purpose of improving mechanical properties such as microhardness, residual stress, wear resistance, and fatigue performance. There are more and more investigations to report the combining manufacturing process of metallic alloys through AM and LSP. In this perspective, the fundamental mechanisms of AM and LSP were summarized in detail. The combining manufacturing process with LSP and AM was introduced from the aspect of residual stress, microhardness, fatigue performance, wear resistance, and microstructure evolution. Also, the microstructure-property relationship was discussed to explain the strengthening mechanism of AMed components by LSP. This work has important reference value and guidance significance for researchers to widespread the accepted LSP as a postprocessing method in the fields of AM.
The efficacy of optimal medical therapy (OMT) with or without revascularization therapy in patients with stable coronary artery disease (SCAD) remains controversial. We performed a meta-analysis of randomized controlled trials (RCTs) that compared OMT with or without revascularization therapy for SCAD patients.
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