Letter to the Editor Regarding “Ticagrelor for Asian Patients With Acute Coronary Syndrome in Real-World Practice: A Systematic Review and Meta-analysis of Observational Studies.” The Benefit of Using Person-Year When the Follow-up Period Varies in a Meta-analysis

Importance: Up to 10% of patients with acute myocardial infarction (AMI) have right bundle branch block (RBBB), and RBBB has been associated with a higher risk of mortality. We performed a systematic review and meta-analysis to determine the prognostic significance of RBBB for patients with AMI. Acute coronary syndrome (ACS) Data Sources: We have systematically searched Ovid, Scopus and Web of Science through January 2014. Study Selection: Reviewers working independently and in duplicate screened all eligible abstracts, selecting studies that described all-cause mortality or cardiovascular death in patients with RBBB and suspected ACS. We excluded studies that reported unadjusted outcomes. Knowledge synthesis: We pooled risk ratio with hazard ratio in studies reporting those outcomes. When reported, odds ratio was converted into risk ratio using reported event rate in each study’s unexposed -read: non RBBB- group. Main Outcomes: All-cause mortality and cardiovascular mortality (death). Results: Eighteen studies were found that reported eligible data. All were observational studies, involving over 89,000 patients. In short-term follow up (up to 30 days), RBBB on presentation was associated with higher all-cause mortality rate, compared to patients without RBBB (RR 2.23, 95% CI 1.76-2.82). There was a trend for higher mortality at long-term follow up (range: 6 months-16 years) that did not reach statistical significance (RR 1.45, 95% CI 0.93-2.25). Figure-1 demonstrates the forest plot. Risk of bias was assessed with the Newcastle-Ottawa scale and majority of included studied were deemed moderate to high quality. Conclusion and Relevance: RBBB is associated with a more than 2-fold higher risk of all-cause mortality in patients with AMI at 30 days follow up. Patients with AMI and RBBB represent a high risk group for adverse outcomes. A sentence on the differential findings for new vs. old RBBB and association with outcomes could follow here.

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Left dominant circulation increases mortality in acute coronary syndrome: A systematic review and meta-analysis of observational studies involving 255,718 patients

Catheterization and Cardiovascular Interventions ◽

10.1002/ccd.26281 ◽

2015 ◽

Vol 88 (2) ◽

pp. 201-208 ◽

Cited By ~ 4

Author(s):

Abdur R. Khan ◽

Faraz Khan Luni ◽

Chirag Bavishi ◽

Sobia Khan ◽

Ehab A. Eltahawy

Keyword(s):

Systematic Review ◽

Acute Coronary Syndrome ◽

Observational Studies ◽

Meta Analysis ◽

Coronary Syndrome

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Morphine in acute coronary syndrome: systematic review and meta-analysis

BMJ Open ◽

10.1136/bmjopen-2018-025232 ◽

2019 ◽

Vol 9 (3) ◽

pp. e025232 ◽

Cited By ~ 6

Author(s):

Gonçalo Silva Duarte ◽

Afonso Nunes-Ferreira ◽

Filipe Brogueira Rodrigues ◽

Fausto J Pinto ◽

Joaquim J Ferreira ◽

...

Keyword(s):

Systematic Review ◽

Acute Coronary Syndrome ◽

Hospital Mortality ◽

Observational Studies ◽

Platelet Reactivity ◽

Meta Analysis ◽

Low Grade ◽

Coronary Syndrome ◽

Increased Risk ◽

The Impact

ObjectiveMorphine 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.DesignSystematic review and meta-analysis.Data sourcesCENTRAL, MEDLINE, EMBASE and trial registries.Eligibility criteria for selecting studiesWe included RCTs and observational studies evaluating the impact of morphine in cardiovascular outcomes or platelet reactivity measures.Data extraction and synthesisData 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.ResultsFive 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.ConclusionsMorphine 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 numberCRD42016036357.

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Ticagrelor versus clopidogrel in East Asian patients with acute coronary syndrome: Systematic review and meta-analysis

Cardiovascular Revascularization Medicine ◽

10.1016/j.carrev.2018.01.009 ◽

2018 ◽

Vol 19 (6) ◽

pp. 689-694 ◽

Cited By ~ 13

Author(s):

Naoki Misumida ◽

Shunsuke Aoi ◽

Sun Moon Kim ◽

Khaled M. Ziada ◽

Ahmed Abdel-Latif

Keyword(s):

Systematic Review ◽

Acute Coronary Syndrome ◽

Meta Analysis ◽

East Asian ◽

Coronary Syndrome ◽

Asian Patients ◽

East Asian Patients

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Is the use of two versus one long-acting bronchodilator by patients with COPD associated with a higher risk of acute coronary syndrome in real-world clinical practice?

BMJ Open Respiratory Research ◽

10.1136/bmjresp-2020-000840 ◽

2021 ◽

Vol 8 (1) ◽

pp. e000840

Author(s):

Lianne Parkin ◽

Sheila Williams ◽

David Barson ◽

Katrina Sharples ◽

Simon Horsburgh ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Clinical Practice ◽

Real World ◽

Chronic Obstructive ◽

Treatment Intensification ◽

Cardiovascular Comorbidity ◽

Coronary Syndrome ◽

Long Acting ◽

The Impact

BackgroundCardiovascular comorbidity is common among patients with chronic obstructive pulmonary disease (COPD) and there is concern that long-acting bronchodilators (long-acting muscarinic antagonists (LAMAs) and long-acting beta2 agonists (LABAs)) may further increase the risk of acute coronary events. Information about the impact of treatment intensification on acute coronary syndrome (ACS) risk in real-world settings is limited. We undertook a nationwide nested case–control study to estimate the risk of ACS in users of both a LAMA and a LABA relative to users of a LAMA.MethodsWe used routinely collected national health and pharmaceutical dispensing data to establish a cohort of patients aged >45 years who initiated long-acting bronchodilator therapy for COPD between 1 February 2006 and 30 December 2013. Fatal and non-fatal ACS events during follow-up were identified using hospital discharge and mortality records. For each case we used risk set sampling to randomly select up to 10 controls, matched by date of birth, sex, date of cohort entry (first LAMA and/or LABA dispensing), and COPD severity.ResultsFrom the cohort (n=83 417), we identified 5399 ACS cases during 281 292 person-years of follow-up. Compared with current use of LAMA therapy, current use of LAMA and LABA dual therapy was associated with a higher risk of ACS (OR 1.28 (95% CI 1.13 to 1.44)). The OR in an analysis restricted to fatal cases was 1.46 (95% CI 1.12 to 1.91).ConclusionIn real-world clinical practice, use of two versus one long-acting bronchodilator by people with COPD is associated with a higher risk of ACS.

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