Эпизоды
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Does Timing of Coronary Artery Bypass Grafting after ST-Elevation Myocardial Infarction Impact Early- and Long-Term Outcomes?
DOI: 10.1055/s-0044-1787851
Abstract
Background: The optimal timing of surgicalrevascularization after ST-elevation myocardial infarction (STEMI) is controversial, with some suggesting higher mortality rates in patients undergoing early surgery. The aim of the study is to determine the effect of the timing of surgical revascularization on 30-day mortality and long-termoutcomes in these patients.
Methods: Retrospective single-center analysis ofpatients with ST-elevation myocardial infarction undergoing coronary artery bypass grafting (CABG) between January 2008 and December 2019 at our institution. The cohort was split into three groups based on time from symptomonset until surgical revascularization (Group 1: <12 hours, Group 2: 12-72 hours, Group 3: >72 hours). Statistical analyses were performed with and without patients in cardiogenic shock. Primary outcomes were 30-day mortality and10-year survival.
Results: During the study period, 437 consecutive patients underwent surgical revascularization in the setting ofSTEMI. The mean age was 67.0 years, 96 (22.0%) patients were female, and 281 (64.3%) patients underwent off-pump CABG. The overall 30-day mortality includingpatients with cardiogenic shock was 12.8%. The 30-day mortality was 16.1, 13.9, and 9.3% in Groups 1, 2, and 3 (p = 0.31), whereas 10-year survival was 48.5, 57.3,and 54.9% (log-rank: p =0.40). After exclusion of patients in cardiogenic shock, there was no difference between the three groups in 30-day and 10-year mortality. Timing ofsurgery had no influence on early- and long-term survival.
Conclusion: In patients with ST-elevationmyocardial infarction, early surgical revascularization achieved similar early- and long-term survival rates compared with a delayed surgical revascularizationstrategy. Hence, when indicated, an early coronary artery bypass grafting strategy has no disadvantages in comparison to a delayed strategy.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Rationale and Design of the TADCLOT Trial: A Double Blind Randomized Controlled Trial Comparing Twice a DayClopidogrel vs. Ticagrelor in Reducing Major Cardiac Events in Patients with Acute STEMI Undergoing Primary Percutaneous Coronary Intervention
DOI: 10.1016/j.ahj.2025.03.021Abstract
Background: Ticagrelor has been proven superior toclopidogrel in reducing adverse cardiovascular events in patients with acute coronary syndrome (ACS), yet economic factors often favor clopidogrel in real-world clinical practice. Although double dose clopidogrel has shownpotential benefits over once-daily regimens, its direct comparison with ticagrelor in ST-elevation myocardial infarction (STEMI) patients remains unexplored.
Methods and design: Twice a Day Clopidogrel vs.Ticagrelor in Reducing Major Cardiac Events in Patients with Acute STEMI Undergoing Primary PCI (TADCLOT) trial is a double-blind, randomized controlled trial conducted at the National Institute of Cardiovascular Diseases (NICVD),Karachi, Pakistan. It is designed as a superiority trial to evaluate the efficacy and safety of ticagrelor over twice-daily clopidogrel in reducing major adverse cardiac events (MACE) in STEMI patients undergoing primary percutaneous coronary intervention (PCI). Following successful PCI for STEMI, and when the patient is deemed suitable for discharge, patients are randomized 1:1 to receive either ticagrelor (180 mg loading dose followed by 90 mg BID for30 days) or clopidogrel (600 mg loading dose followed by 75 mg BID for 30 days). The primary endpoint is the rate of major adverse cardiac events (MACE), a composite of death, myocardial infarction, stent thrombosis, target lesionrevascularization, or stroke at 30 days following randomization. Secondary endpoints include the individual components of MACE, bleeding complications, and drug discontinuation due to adverse events. Enrollment has reached 88%, with 2,200 patients planned to complete the trial.
Implications: The TADCLOT trial will provide crucialinsights into the comparative efficacy of ticagrelor versus twice-daily clopidogrel in reducing early stent thrombosis and improving outcomes in STEMI patients undergoing primary PCI. The trial will particularly contributevaluable insights for post-PCI care, considering both the economic and genetic context of the high risk South Asian population.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Пропущенные эпизоды?
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In-hospital use of beta-blockers for critically ill patients with acute heart failure: Whether and when to initiate
DOI: 10.1016/j.jclinane.2025.111824
Abstract
Background: The use of beta-blockers during hospitalization for acute heart failure (AHF) remains controversial. This study aimed to investigate whether beta-blocker use isassociated with a reduced risk of mortality in critically ill patients with AHF and to determine the optimal timing for initiating beta-blocker therapy.
Methods: Data from critically ill patients with AHF in the MIMIC-IV version 2.2 database were analyzed.Baseline characteristics, laboratory tests, comorbidities, vital signs, and medication usage at admission and during hospitalization were collected to performinverse probability of treatment weighting (IPTW). IPTW-weighted logistic regression models were then used to examine the relationship between beta-blocker use and mortality.
Results: In the IPTW-weighted regression model, patients who newly started beta-blockers or continued theiruse had a lower risk of in-hospital mortality compared to those not treated with beta-blockers (oddsratio [OR]: 0.45; 95 % confidence interval [CI]: 0.34 to 0.61, and OR: 0.53; 95 % CI: 0.41 to 0.69, respectively). Conversely, those who had beta-blockers withdrawn showed a higher risk of in-hospital mortality (OR: 2.59; 95 % CI: 1.63 to4.10). Among beta-blocker users, compared to patients treated before admission and who received their first dose within 48 h of admission, those whowere not treated before admission but started after 48 h had a similar mortality risk (OR: 0.82; 95 % CI: 0.60 to 1.11; P = 0.202). However, patients previously treated with beta-blockers who initiated therapy after 48 h and those not treated before admission but started within 48 h had a lower risk of in-hospital mortality (OR: 0.44; 95 % CI: 0.30 to 0.64; P < 0.001, and OR: 0.65; 95 % CI: 0.48 to 0.86; P = 0.003,respectively).
Conclusion: The use of beta-blockers during hospitalization for AHF is associated with a reduced risk of in-hospital mortality, and withdrawal was associated with an increased risk of mortality. Initiating beta-blockers within 48 h for beta-blocker-naïve patients and after 48 h for those previously treated with beta-blockers before admission may further decrease mortality risk.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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1. Dual antiplatelet therapy is recommended for patients with acute coronary syndromes (ACS). Ticagrelor or prasugrel is recommended in preference to clopidogrel in patients with ACS who are undergoing percutaneous coronary intervention (PCI). In patients with non–ST-segment elevation ACS who are scheduled for an invasive strategy with timing of angiography to be >24 hours, upstream treatment with clopidogrel or ticagrelor may be considered to reduce major adverse cardiovascular events.
2. Dual antiplatelet therapy with aspirin and an oral P2Y12 inhibitor is indicated for at least 12 months as the default strategy in patients with ACS who are not at high bleeding risk. Several strategies are available to reduce bleeding risk in patients with ACS who have undergone PCI and require antiplatelet therapy: (a) in patients at risk for gastrointestinalbleeding, a proton pump inhibitor is recommended; (b) in patients who have tolerated dual antiplatelet therapy with ticagrelor, transition to ticagrelor monotherapy is recommended ≥1 month after PCI; or (c) in patients who require long-term anticoagulation, aspirin discontinuation is recommended 1 to 4 weeks after PCI with continued use of a P2Y12 inhibitor (preferably clopidogrel).
3.High-intensity statin therapy is recommended for all patients with ACS, and with the option to initiate concurrent ezetimibe. A nonstatin lipid-lowering agent (eg, ezetimibe,evolocumab, alirocumab, inclisiran, bempedoic acid) is recommended for patients already on maximally tolerated statin who have a low-density lipoprotein cholesterol level of ≥70 mg/dL (1.8 mmol/L). It is reasonable in this high-risk population to further intensify lipid-lowering therapy if the low-density lipoprotein cholesterol level is 55 to <70 mg/dL (1.4 to <1.8 mmol/L) and patient is already on a maximally tolerated statin.
4.In patients with non–ST-segment elevation ACS who are at intermediate or high risk of ischemic events, an invasive approach with the intent to proceed with revascularization is recommended during hospitalization to reduce major adverse cardiovascular events. In patients with non–ST-segment elevation ACS who are at low risk of ischemic events, a routine invasive or selective invasive approachwith further risk stratification is recommended to help identify those who may require revascularization and to reduce major adverse cardiovascular events.
5. Two procedural strategies are recommended in patients with ACS who are undergoing PCI: (a) radial approach is preferred over femoral approach in patients withACS undergoing PCI to reduce bleeding, vascular complications, and death; and (b) intracoronary imaging is recommended to guide PCI in patients with ACS withcomplex coronary lesions.
6. A strategy of complete revascularization is recommended in patients with ST-segment elevation myocardial infarction or non–ST-segment elevation ACS. The choice of revascularization method (ie, coronary artery bypass graft surgery versus multivessel PCI) in non–ST-segment elevation ACS and multivessel disease should be based on the complexity of the coronary artery disease and comorbidconditions. PCI of significant nonculprit stenoses for patients with ST-segment elevation myocardial infarction can be performed in a single procedure or staged with some preference toward performing multivessel PCI in a singleprocedure. In patients with ACS and cardiogenic shock, emergency revascularization of the culprit vessel is indicated; however, routine PCI of non–infarct-related arteries at the time of PCI is not recommended.
7. Red blood cell transfusion to maintain a hemoglobin of 10 g/dL may be reasonable in patients with ACS and acute or chronic anemia who are not actively bleeding.
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Early β-Blocker Use and Clinical Outcomes in Acute Myocardial Injury: A Retrospective Cohort Study
https://doi.org/10.1016/j.amjmed.2025.02.029
Abstract
Background
Acute myocardial injury is defined by elevated cardiactroponin (cTn) levels with a rising and/or falling pattern, and is associated with increased mortality risk compared to patients without myocardial injury. The role of β-blockers in patients with acute myocardial injury remains unclear.
Methods
This multicenter, retrospective cohort study used data fromthe Tianjin Health and Medical Data Platform to assess the impact of early β-blocker use on 1-year all-cause mortality and major adverse cardiovascular events (MACE) in acute myocardial injury patients, employing a new user andtarget trial emulation design. Propensity score matching (PSM) was applied, and Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI).
Results
After PSM, a total of 25,966 participants were included:8,667 to the β-blocker group and 17,299 to the non-β-blocker group. A total of 3,487 deaths (13.5%) and 5,795 MACE (22.3%) occurred. Compared with non-users,β-blocker was associated with the reduced risk of all-cause mortality (HR: 0.89, 95% CI: 0.83-0.95) and MACE (HR: 0.90, 95% CI: 0.85-0.95). In the subgroup analysis, β-blockers were associated with a significantly reduced risk of mortality in patients without stroke (HR 0.85, 95% CI: 0.78–0.93),while no significant association was observed in patients with stroke (HR 1.04, 95% CI: 0.93–1.16).
Conclusions
Early use of β-blockers is associated with the reduced riskof 1-year mortality in patients with acute myocardial injury. To more accurately assess the therapeutic effects, prospective trials are necessary, and these data provide key research directions for future trials.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Impact of Metabolic Syndrome on Clinical Profile and Prognosis in Patients with Acute ST-Elevation MyocardialInfarction: a Cross-Sectional Study
https://link.springer.com/article/10.1007/s42399-025-01822-6Abstract
Metabolic syndrome (MS) has gained attention as a newly discovered risk factor for coronary artery disease (CAD).Studies have demonstrated that individuals with MS have a higher risk for coronary artery disease (CAD), and the risk is higher in females compared to males. Patients with metabolic syndrome have a higher incidence of ST-elevationmyocardial infarction (STEMI), making it a significant risk factor that has to be well-treated for successful secondary prevention. The study’s objective is to determine the frequency of MS in patients with acute STEMI according to the new “obesity-centric” IDF definition and to compare the clinical outcomes of acute STEMI patients with and without MS. A total of 132 consecutive patients with acute STEMI were analyzed, and 100 patients were included. MS wasidentified using criteria based on the “International Diabetes Federation 2005.” The frequency of metabolic syndrome in patients with STEMI was 46%. The frequency was greater in females (53.2%) than in males (43.2%). Patients whohad MS had poor clinical outcomes when compared to patients without MS, including mortality. Mortality due to STEMI in patients with MS was 15.2%, whereas in patients without MS was just 2% (p < 0.05). In addition to being a significant risk factor for cardiovascular disease, metabolic syndrome can also be a strong predictor of the severity and immediate prognosis of the condition.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Assessing the application of American Heart Association (AHA) guidelines in the management of heart failure withreduced ejection fraction
https://link.springer.com/article/10.1186/s43044-025-00629-zHeart failure (HF) is a significant global health issue. Appropriate and timely treatment at target doses significantly reduces mortality and enhances quality of life. However, studies indicate suboptimal pharmacotherapy among patients. This study aims to assess the medical treatment of patients with heart failure and reduced ejection fraction (HFrEF) and their adherence to the American Heart Association (AHA) guidelines. The study was designed as a cross-sectional analysis in the cardiac departmentof Razi Hospital in Birjand from March 20, 2020, to March 11, 2023, focusing on patients with left ventricular ejection fraction less than or equal to 40%. Data were extracted from patients’ medical records. Medications were classifiedaccording to the four-pillar therapy recommended by the American Heart Association, including β-blockers, Angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitors/ARBs, SGLT2, and MRAs. Patients were grouped based on their treatment regimens. The percentage of achieved target doses for each medication was categorized as follows: 0–25%, 25–50%, 50–99%, and 100%. Statistical analysis was conducted using SPSS version 22.
Results
The study included patients with a mean ageof 66 ± 13.7 years, of whom 278 (69%) were male. The mean ejection fraction was 26.8 ± 9.6%, and the most prevalent comorbidity was coronary artery disease (CAD) observed in 68.0% of patients. The in-hospital mortality rate was 5%. Theresults revealed that only 20% were on quadruple therapy, while 10% received none of the recommended medications. The prescription rates for key medications were as follows: β-blockers 76.4%, ACE inhibitors/ARBs 71.6%, MRA 63.3%, SGLT2I 33.5%, and ARNI 0%. Notably, 94.8% of prescribed SGLT2I doses met the target dose, while 84.4% of β-blocker prescriptions and 61.8% of ACEI/ARB prescriptions werebelow 75% of the target dose.
Conclusion
The findings reveal significant gaps in the prescription of essential therapies, including MRAs and ARNIs, which arecrucial for managing myocardial dysfunction. Addressing these gaps underscores the necessity for ongoing education and training for healthcare providers in heart failure management.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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The “Silent Enemy” Called Renal Artery Stenosis: A Mini-Review:
J. Vasc. Dis. 2025, 4(1), 10; https://doi.org/10.3390/jvd4010010
Renal artery stenosis (RAS) is a vascular condition characterized by narrowing of one or both renal arteries, leading to reduced blood flow to the kidneys, activation of the renin–angiotensin–aldosterone system (RAAS), and subsequent renovascular hypertension. Overactivation of the same cascade potentiates the production of angiotensin II, which induces systemic vasoconstriction, increases sodium and water retention via aldosterone, and activates the sympathetic nervous system. Angiotensin II is also implicated in endothelial dysfunction, oxidative stress,and chronic inflammation, thus impairing vascular remodeling and arterial stiffness, all of which serve to accelerate cardiovascular complications, suchas left ventricular hypertrophy, heart failure, and myocardial infarction. Renal artery stenosis is usually due in at least 90% of cases to atherosclerosis, which typically affects older people with diabetes and smoking as risk factors.There are two types of Renal artery stenosis: unilateral and bilateral. Bilateral Renal artery stenosis is commonly associated with flash pulmonary edema, a life-threatening emergency condition in which alveolar space floodingcan occur within minutes. Renal artery stenosis typically remains asymptomatic until the late stage with complications of hypertension, ischemic nephropathy,or chronic kidney disease. FMD tends to create structural abnormalities of the artery, whereas atherosclerosis causes plaque formation and endothelial dysfunction of the artery. Epidemiological surveys have revealed that theprevalence of Renal artery stenosis ranges from 4% to 53% and is especially high among patients with hypertension, cardiovascular disease, or CKD. Diagnosis is based on clinical suspicion and supported by imaging studies, including Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography. Early detection also relies on certain laboratory biomarkers, especially in identifying high-risk patients. These markers wouldinclude increased plasma renin activity, elevated aldosterone-renin ratio, and inflammatory markers, including C-reactive protein and endothelin-1. Treatmentwould also involve pharmacological approaches, including the renin–angiotensin–aldosterone system inhibitors, beta-blockers, and statins, and interventional treatments, including angioplasty and stenting in patientswith severe forms of the disease. However, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) Trial showed that most patients would likelyrequire medical therapy, and that intervention should be reserved for those with uncontrolled hypertension, progressive renal dysfunction, or recurrent episodes of pulmonary edema. Other emerging therapies include drug-eluting balloons, bioresorbable stents, and gene-editing techniques, all of which have shown great promise in the few studies that have been conducted, although further evaluation is needed. Despite these advances, there are still gaps in knowledge regarding patient stratification, biomarker validation, and the development of personalized treatment strategies. This article reviews thecomplexities of the renin–angiotensin–aldosterone system and its systemic impact on cardiovascular and renal health. Future research can therefore focus on improving early diagnosis, optimizing patient selection for intervention,and developing new therapies to slow disease progression and mitigate complications.
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Impact of controlled stepwise reperfusion during primary percutaneous coronary intervention on patients with ST-elevation myocardial infarction
Abstract
Objective:
The aim of this study is to examine the impact of controlled stepwise reperfusion by modulating pre-dilation balloonpressure during primary percutaneous coronary interventions (PPCI) in patients with ST-elevation myocardial infarction (STEMI).
Methods:
Consecutive ST-elevation myocardial infarction patients requiring primary percutaneous coronary interventions withthrombolysis in myocardial infarction (TIMI) flow grades 0 or 1, were randomly divided into an experimental group and a control group. For the control group, the pre-dilation balloon was removed immediately after achieving antegradeperfusion beyond the lesion. The experimental group underwent stepwise reperfusion, with the balloon pressure being gradually reduced. Baseline data, intra/post-procedural primary percutaneous coronary interventions data, 3-month left ventricular ejection fraction (LVEF), and major adverse cardiac events (MACE) were documented and compared between the two groups.
Results:
The control group experienced more severe symptoms during the procedure (p = 0.034), higher post-procedural corrected TIMI frame counts (p = 0.047), more significant hemodynamic changes (p = 0.031), and increased rates of ventricular tachycardia/ventricular fibrillation (p = 0.035). Additionally, they had a higher total number of arrhythmias (p = 0.017), a lower 90-min ST segment resolution rate (p = 0.045), and elevated cTNI levels one week after the procedure (p = 0.047). Three months later, the control group demonstrated a lower LVEF compared to the experimental group (p = 0.048) and a trend towards more drug-treated arrhythmias (p = 0.073). No differences were observedin other statistical results.
Conclusion:
In patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary interventions, controlled stepwise reperfusion by adjusting the pre-dilation balloon pressure effectively reduces myocardial ischemia-reperfusion injury, improves myocardial perfusion,and supports the recovery of cardiac function.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Triglyceride glucose-waist circumference as a predictor of mortality and subtypes of cardiovascular disease: asystematic review and meta-analysis
DOI https://doi.org/10.1186/s13098-025-01616-9
Abstract
Background
The significant burden of cardiovascular diseases underscores the necessity for identifying novel predictive markers that can forecast both cardiovascular diseases and mortality. In recent years, Triglycerideglucose -obesity-related parameters have gained special attention in thisregard. This study aimed to assess the association between Triglyceride glucose -waist circumference (TyG-WC) and cardiovascular diseases and mortality.
Methods
A comprehensive search was performed in databases including PubMed, Scopus, and Web of Science from their inception until October 6, 2024. The key outcomes of interest included all-cause mortality, cardiovascular mortality, cardiovascular diseases, myocardialinfarction, stroke, coronary artery diseases, peripheral artery diseases, and heart failure. The pooled risk ratio (RR) with corresponding 95% confidence intervals (CI) was calculated. Meta-analysis was carried out using StataMP 14.0.
Results
A total of 17 studies were included in the analysis. The number of participants ranged between 2,224 and 95,342. The meta-analysis revealed that Triglyceride glucose -waist circumference is significantly associated with an increased risk of all-cause mortality, cardiovascular mortality, cardiovascular diseases, myocardial infarction,stroke, coronary artery diseases, and peripheral artery diseases. However, only one study addressed the relationship between Triglyceride glucose -waist circumference and heart failure with a positive correlation.
Conclusion
This study indicates that Triglyceride glucose -waist circumference could serve as a promising predictor ofcardiovascular diseases, along with cardiovascular and all-cause mortality. Given its accessibility, Triglyceride glucose -waist circumference may be a practical tool for screening purposes.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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The use of beta-blockers for heart failure with reduced ejection fraction in the era of SGLT2 inhibitors – are westill afraid to up-titrate?
DOI https://doi.org/10.1007/s00380-025-02525-7
Beta-blockers are one of the four major pillars of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF). The therapy has presented the best effects when up-titrated to evidence-based target doses. Despite their proven benefits, physicians have traditionally shown reluctance to up-titrate beta-blockersbecause of their negative inotropic and chronotropic effects. The effects of newly introduced sodium-glucose cotransporter 2 inhibitors (SGLT2I) in treatingheart failure with reduced ejection fraction might open more room for adequate beta-blockers up-titration. The goal of this study was to evaluate the up-titration practice, and impact of target doses of beta-blockers in patientswith heart failure with reduced ejection fraction receiving sodium-glucose cotransporter 2 inhibitors. This is a prospective cohort study involving patients with heart failure with reduced ejection fraction receiving sodium-glucose cotransporter 2 inhibitors therapy. Baseline use and dosing to the evidence-based targets were examined. We compared the groups of patients receiving maximally titrated beta-blockers versus incompletely titrated.Primary outcome was composite of (1) rehospitalization or revisit to emergency unit due to the heart failure; (2) all-cause death and major adverse cardiac events (MACE). Secondary outcomes were heart rate at rest, left ventricularejection fraction, N-terminal pro-B-type natriuretic peptide, and New York Heart Association status at 6 and 12 months of follow-up. Study endpoints were documented via telephone interviews, regular outpatient follow-up, or by electronic hospital records. This study included a total of 458 patients with median follow-up time of 365 (186–502) days. A total of 122 (26.6%) patients had beta-blockers maximally up-titrated. The results show that adherence to maximal target doses of β-blocker therapy significantly reduces hazard of death or Major adverse cardiac events comparing to not using maximal doses of β-blocker (factor 0.43). Hazard reduction was not statistically significant for composite of rehospitalization or revisit to emergency unit due to HF. Maximal doses of beta-blockers did not result in a significant decrease in resting heart rate. Our real-world data have highlighted the prevalence of incomplete titration of beta-blockers. Although it has been shown that evidence-basedtarget dosing of beta-blockers reduces death and Major adverse cardiac events, there is still room for improvement with up-titrating beta-blockers in eligible patients.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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De-escalating Dual Antiplatelet Therapy to Ticagrelor Monotherapy in Acute Coronary Syndrome : A Systemic Review and Individual Patient Data Meta-Analysis of Randomized Clinical Trials
Ann Intern Med . 2025 Feb 18. doi: 10.7326/ANNALS-24-03102.
Abstract
Background: The role of transitioning from shortdual antiplatelet therapy (DAPT) to potent P2Y12 inhibitor monotherapy in patients with acute coronary syndrome (ACS) undergoing drug-eluting stent (DES)implantation remains inconclusive.
Purpose: To compare the effects of de-escalatingdual antiplatelet therapy to ticagrelor monotherapy versus standard dual antiplatelet therapy from randomized clinical trials in patients with acute coronary syndrome.
Data sources: PubMed, EMBASE, Scopus, andClinicalTrials.gov from inception to 12 December 2024.
Study selection: Randomized clinical trialscomparing de-escalating dual antiplatelet therapy to ticagrelor monotherapy versus ticagrelor-based standard dual antiplatelet therapy for 12 months, specifically in patients with acute coronary syndrome undergoing drug-eluting stent implantation.
Data extraction: The coprimary end points werean ischemic end point (composite of death, nonprocedural [spontaneous] myocardial infarction, or stroke) and a bleeding end point (Bleeding Academic Research Consortium types 3 or 5 bleeding).
Data synthesis: Individual patient data wereobtained from 3 trials (TICO [Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome], T-PASS [Ticagrelor Monotherapy in Patients Treated With New-Generation Drug-Eluting Stents for Acute Coronary Syndrome], and ULTIMATE-DAPT [Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 afterpercutaneous coronary intervention in patients with acute coronary syndromes]), including 9130 randomized patients with acute coronary syndrome; 3132 had ST-segment elevation myocardial infarction (STEMI), 3023 had non-STEMI (NSTEMI), and 2975 had unstable angina. The rate of the primary ischemic end point was not different between the ticagrelor monotherapy and standard dualantiplatelet therapy groups (1.7% vs. 2.1%; hazard ratio [HR], 0.85 [95% CI, 0.63 to 1.16]). The rate of the primary bleeding end point was lower in the ticagrelor monotherapy group (0.8% vs. 2.5%; HR, 0.30 [CI, 0.21 to 0.45]). These findings were consistent in patients with ST-segment elevation myocardial infarction, Non ST-segment elevation myocardial infarction, and unstable angina.
Limitation: Other de-escalation strategies for modulating antiplatelet therapy were not included.
Conclusion: In patients with acute coronarysyndrome undergoing drug-eluting stent implantation, de-escalating dual antiplatelet therapy to ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard dual antiplatelet therapy, without an increase in ischemic events, regardless of the type of acute coronary syndrome.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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TICA-CLOP STUDY: Ticagrelor Versus Clopidogrel in Acute Moderate and Moderate-to-Severe Ischemic Stroke, aRandomized Controlled Multi-Center Trial
Randomized Controlled Trial CNS Drugs. 2025Jan;39(1):81-93. doi: 10.1007/s40263-024-01127-7.
Abstract
Background: Many studies evaluated the efficacyand safety of ticagrelor versus clopidogrel in patients with ischemic stroke; none of these trials included North African participants, and all of these trials comprised only participants who experienced transient ischemic attack(TIA) or minor stroke.
Objectives: We compared the efficacy and safety of ticagrelor versus clopidogrel in patients with first-ever noncardioembolic moderate or moderate-to-severe ischemic stroke.
Methods: Our trial involved 900 first-ever noncardioembolic patients with acute ischemic stroke (AIS) who randomlyreceived either loading and maintenance doses of ticagrelor or clopidogrel within the first 24 hour of stroke onset.
Results: We involved 900 patients in the intention-to-treat analysis. A total of 39 (8.7%) patients in ticagrelor armand 62 (13.8%) in clopidogrel arm experienced a new stroke [hazard ratio (HR) 0.46; 95% confidence interval (CI) 0.34-0.83; P value = 0.006]. A total of 57 (12.7%) patients in ticagrelor group and 80 (17.8%) patients in clopidogrelgroup experienced composite of new stroke, myocardial infarction (MI), or death due to vascular insults (HR0.51; 95% CI 0.43-0.82; P value = 0.004). Participants who received ticagrelor experienced less frequent unfavorable outcomes. We found no significant variation between our study's two arms concerning the hemorrhagic and non-hemorrhagic complications.
Conclusion: Patients with noncardioembolic moderate or moderate-to-severe ischemic stroke who received ticagrelor within the first 24 h after ischemic stroke had better clinical outcomes based on recurrent stroke rates and unfavorable modified Rankin Scale (mRS) rates compared with those who received clopidogrel. There were no significant variations between ticagrelor and clopidogrel regarding hemorrhagic and non-hemorrhagic complications.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Examining the Specificity of Smartphone ECG Devices in Decision-Making for ST-Elevation Myocardial Infarction andNon-ST-Elevation Myocardial Infarction
DOI: https://doi.org/10.30701/ijc.1740
Abstract
Background & Objectives: Electrocardiography(ECG) stands as a cornerstone diagnostic tool for assessing cardiac health, particularly in ruling out abnormalities. The integration of smartphone devices presents a promising avenue for expedited detection of cardiac irregularities.This study aims to evaluate the diagnostic efficacy of smartphone ECG devices in subjects admitted to Cardiac Care Units (CCUs) and Cardiac Intensive CareUnits (CICUs).
Methods: A retrospective analysis was conducted on acohort comprising 62 patients presenting with cardiac symptoms. Utilizing smartphone ECG devices as the index, 12-lead ECG tests were administered alongside the Gold Standard ECG machine for comparison among patients in Cardiac Care Units and Cardiac Intensive Care Units. Diagnostic decisions concerning the presence of ST-Elevation Myocardial Infarction (STEMI) or Non-ST-ElevationMyocardial Infarction (NSTEMI) were made by a team of cardiologists following a meticulous review of both sets of ECG reports.
Results: Data analysis was conducted on 56 patients.The smartphone-based ECG device exhibited 100% specificity, 93% sensitivity, 80% Negative Predictive Value, and 100% Positive Predictive Value, yielding an F-score of 0.96 and a Mathew Correlation Coefficient value of 0.86.
This study unequivocally underscores the significantpotential of the Spandan ECG device in accurately identifying a range of cardiac abnormalities, including critical conditions such as ST-Elevation Myocardial Infarction and ischemia. Despite its portable nature, smartphone ECGtechnology demonstrates utility within Critical Care Units for timely monitoring and diagnosis.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Metoprolol vs diltiazem for atrial fibrillation with rapid ventricular rate: Systematic review and meta-analysisof adverse events
https://doi.org/10.1016/j.ajem.2024.12.070
Abstract
Background
Intravenous (IV) diltiazem and metoprololare commonly used to achieve rate control for atrial fibrillation with rapid ventricular rate (Afib with RVR), and are both recommended as first-line by current guidelines. While prior studies investigated the efficacy of thesemedications, there is little evidence available regarding the risk of adverse events (AEs) with their use.
Methods
We identified randomized controlled trials(RCT) and observational studies reporting rates of adverse events following administration of Intravenous diltiazem and metoprolol for atrial fibrillation with rapid ventricular rate by searching PubMed, SCOPUS, EMBASE, and CochraneLibrary. Our primary outcome was the incidence of adverse events and specifically hypotension and bradycardia, which were examined individually as secondary outcomes. We performed random-effects meta-analysis to identify ratesof each adverse events. We used moderator analysis and meta-regressions to evaluate risk factors. We used the Cochrane Risk-of-Bias 2 tool and the Newcastle-Ottawa Scale to assess study quality.
Results
We reviewed 13 studies and included 1660 patients, 888 (53 %) treated with metoprolol and 772 (47 %) with diltiazem.Metoprolol was associated with a 26 % lower risk of adverse event (total incidence 10 %) compared to diltiazem (total incidence 19 %), (RR 0.74, 95 % CI 0.56–0.98, p = 0.034) with a prediction interval of 0.50–1.10. Patients with higherinitial heart rates faced higher rates of adverse events (Correlation Coefficient 0.11, 95 % CI 0.03–0.19, p = 0.006). There was no difference with respect to rates of bradycardia (RR 0.44, 95 % CI 0.15–1.30, p = 0.14) or hypotension (RR 0.80, 95 % CI 0.61–1.04, p = 0.10).
Conclusion
Atrial fibrillation with rapid ventricular rate treated with metoprolol had lower rates of adverse event (bradycardiaand/or hypotension) compared to those treated with diltiazem. We found no difference in rates of hypotension or bradycardia when individually assessed. Existing data are limited by small sample sizes, variability in dosing, andlimited representation of important patient subgroups.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Impact of beta-blocker up titration on patientsafter transcatheter edge-to-edge mitral valve repair for secondary mitral regurgitation: The OCEAN-mitral registry
https://doi.org/10.1016/j.ijcard.2024.132595
Abstract
Background
Optimal medical therapy for patients with secondary mitralregurgitation (SMR) undergoing transcatheter edge-to-edge mitral valve repair (M-TEER) remains unclear. This study aimed to investigate the association between beta-blocker up titration and clinical outcomes after mitral transcatheteredge-to-edge repair.
Methods
Using data from the Japanese multicenter registry, weexamined 1474 patients who underwent mitral transcatheter edge-to-edge repair for secondary mitral regurgitation between April 2018 and June 2021. Beta-blocker up titration was defined as an increased dose of beta-blockers 1 month after mitral transcatheter edge-to-edge repair comparedwith that before mitral transcatheter edge-to-edge repair. The 2-year clinical outcomes were compared betweenpatients with and without beta-blocker up titration, utilizing multivariable Cox regression analyses andpropensity score matching (PSM).
Results
Of the 1474 patients who underwent mitral transcatheter edge-to-edge repair, 272 (18.4 %) were receiving increasing doses of beta-blockers at the 1-month follow-up. These patients had lower left ventricular ejection fraction (LVEF)and higher B-type natriuretic peptide levels. Most patients in the beta-blocker up titration group received less than the target dose of beta-blockers. Multivariable Coxregression analyses showed that beta-blocker up titration was significantly associated with a lower risk of all-cause (adjusted hazard ratio [HR]: 0.55; 95 % confidence interval [CI]: 0.36–0.84; P = 0.006) and cardiovascular mortalities (adjusted HR: 0.45, 95 % CI: 0.26–0.79, P = 0.006).Propensity score matching analyses revealed consistent findings. Subgroup analyses revealed a significant interaction between beta-blocker uptitration and leftventricular ejection fraction ≤40 % (interaction P = 0.018).
Conclusions
In patients with secondary mitral regurgitation,beta-blocker uptitration after mitral transcatheter edge-to-edge repair was associated with better clinical outcomes, especially in the group with an left ventricular ejection fraction ≤40 %. Efforts to up titrate guideline-directedmedical therapy after mitral transcatheter edge-to-edge repair for secondary mitral regurgitation may be necessary, even if reaching the target dose proves challenging.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Intravascular imaging-guided percutaneous coronary intervention in patients with acute myocardial infarction and cardiogenic shock
Rev Esp Cardiol (Engl Ed) . 2024 Dec;77(12):995-1007.
Abstract
Introduction and objectives: There are no clinicaldata on the efficacy of intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography-guided percutaneous coronaryintervention in patients with acute myocardial infarction (AMI) and cardiogenic shock. The current study sought to evaluate the impact of intravascular imaging-guided percutaneous coronary intervention in patients with acutemyocardial infarction and cardiogenic shock.
Methods: Among a total of 28, 732 patients from thenationwide pooled registry of KAMIR-NIH (November, 2011 to December, 2015) and KAMIR-V (January, 2016 to June, 2020), we selected a total of 1833 patients (6.4%) with acute myocardial infarction and cardiogenic shock who underwent percutaneous coronary intervention of the culprit vessel. The primary endpoint was major adverse cardiovascular events (MACE) at 1 year, a composite of cardiac death, myocardial infarction, repeat revascularization, and definite or probable stent thrombosis.
Results: Among the study population, 375 patients(20.5%) underwent intravascular imaging-guided percutaneous coronary intervention and 1458 patients (79.5%) underwent angiography-guided percutaneouscoronary intervention. Intravascular imaging-guided percutaneous coronary intervention was associated with a significantly lower risk of 1-year major adverse cardiovascular events than angiography-guided percutaneous coronary intervention (19.5% vs 28.2%; HR, 0.59; 95%CI, 0.45-0.77; P<.001), mainly driven by a lowerrisk of cardiac death (13.7% vs 24.0%; adjusted HR, 0.53; 95%CI, 0.39-0.72; P<.001). These results were consistent in propensity score matching (HR, 0.68; 95%CI, 0.46-0.99),inverse probability weighting (HR, 0.61; 95%CI, 0.45-0.83), and Bayesian analysis (Odds ratio, 0.66, 95% credibleinterval, 0.49-0.88).
Conclusions: In acute myocardial infarction patientswith cardiogenic shock, intravascular imaging-guided percutaneous coronary intervention was associated with a lower risk of major adverse cardiovascular events at 1-year than angiography-guided percutaneous coronary intervention, mainly driven by the lower risk of cardiac death.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Global Impact of Optimal Implementation of Guideline-Directed Medical Therapy in Heart Failure
JAMA Cardiol . 2024 Dec 1;9(12):1154-1158. doi: 10.1001/jamacardio.2024.3023.
Abstract
Importance: Guideline-directed medical therapy (GDMT) remains underutilized on a global level, with significant disparities in access to treatment worldwide. The potential global benefits of quadruple therapy on patients with heart failure with reduced ejection fraction (HFrEF) have not yet been estimated.
Objective: To assess the projected population-level benefit of optimal Guideline-directed medical therapy useglobally among patients with heart failure with reduced ejection fraction.
Design, setting, and participants:Estimates for heart failure with reduced ejection fraction prevalence, contraindications to Guideline-directed medical therapy, treatment rates, and the number needed to treat for all-cause mortality at 12 months were derived from previously published sources. Potential lives saved from optimal implementation of quadruple therapy among patients with heart failure with reduced ejection fraction was calculated globally and a sensitivity analysiswas conducted to account for uncertainty in the existing data.
Main outcomes and measures: All-cause mortality.
Results: Of an estimated 28.89million people with heart failure with reduced ejection fraction worldwide, there were 8 2,35 063 (95% CI, 6 296 020-10 762 972) potentially eligible for but not receiving β-blockers, 20, 387 000 (95% CI, 15 867 004-26 184 996)eligible for but not receiving angiotensin receptor-neprilysin inhibitors, 12 223 700 (95% CI, 9 376 895-15 924 973)eligible for but not receiving mineralocorticoid receptor antagonists, and 21 229 170 (95% CI, 16 537 400-27 242 688)eligible for but not receiving sodium glucose cotransporter-2 inhibitors. Optimal implementation of quadruple Guideline-directed medical therapy could potentially prevent 1 188 277 (95% CI, 767 933-1 914 561) deaths over 12 months. A largeproportion of deaths averted were projected in Southeast Asia, Eastern Mediterranean and Africa, and the Western Pacific regions.
Conclusions and relevance: Improvementin use of Guideline-directed medical therapy could result in substantial mortality benefits on a global scale. Significant heterogeneity also exists across regions, which warrants additional study with interventions tailored to country-level differences for optimization of Guideline-directed medicaltherapy worldwide.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Impact of Adherence to Beta-Blockers in Patients With All-Comers ST-Segment Elevation Myocardial Infarction andAccording to Left Ventricular Ejection Fraction at Discharge: Results From the Real-World Registry FAST-STEMI
J Cardiovasc Pharmacol . 2024 Dec 1;84(6):581-589. doi: 10.1097/FJC.0000000000001627.
Abstract
Beta-blockers are a crucial part of post-myocardial infarction (MI) pharmacological therapy. Recent studies haveraised questions about their efficacy in patients without reduced left ventricular ejection fraction (LVEF). This study aims to assess adherence to beta-blockers after discharge for ST-segment elevation myocardial infarction(STEMI) and the impact of adherence on outcomes based on left ventricular ejection fraction at discharge. The retrospective registry FAST-STEMI evaluated real-world adherence to main cardiovascular drugs in patients with ST-segment elevation myocardial infarction between 2012 and 2017 by comparing purchased tablets with expected ones at 1 year through pharmacy registries. Optimal adherence was defined as ≥80%. Primary outcomes included all-cause andcardiovascular death while secondary outcomes were MI, major/minor bleeding events, and ischemic stroke. The study included 4688 patients discharged on beta-blockers. The mean age was 64 ± 12.3 years, 76% were male, and the mean left ventricular ejection fraction was 49.2 ± 8.8%. The mean adherence at 1 year was 87.1%. Optimal adherence was associated with lower all-cause (adjusted hazard ratio, 0.62, 95% confidence interval, 0.41-0.92, P : 0.02) and cardiovascular (adjusted hazards ratio, 0.55, 95% confidence interval, 0.26-0.98, P : 0.043) mortality. In patientswith left ventricular ejection fraction ≤40%, optimal adherence was linked to reduced all-cause and cardiovascular mortality, but this was not found inpatients with either preserved or mildly reduced left ventricular ejection fraction. Predictors of cardiovascular mortality included older age, chronic kidney disease, male gender, and atrial fibrillation. Optimal adherence tobeta-blocker therapy in patients with all-comers ST-segment elevation myocardial infarction reduced all-cause and cardiovascular mortality at 1 year; once stratified by left ventricular ejection fraction, this effect was confirmed only in patients with reduced left ventricular ejection fraction(<40%) at hospital discharge. Impact of adherence to beta-blockers in all-comers ST-segment elevation myocardial infarction patients and according to left ventricular ejection fraction at discharge: results from the real-worldregistry FAST-STEMI.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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A comparison of the effects of ticagrelor and clopidogrel in patients with acute ST-segment elevation myocardialinfarction: a systematic review and meta-analysis of randomized clinical trials
BMC Pharmacol Toxicol. 2024 Dec9;25(1):93. doi: 10.1186/s40360-024-00817-8.
Abstract
Background: Rupture of unstable coronary atherosclerotic plaque leads to acute ST-segment elevation myocardialinfarction (STEMI). Dual anti-platelet therapy is one of the main treatments, and the combination of Aspirin and Clopidogrel is recognized as the standard oralregimen in most cases. Ticagrelor is a new generation of P2Y12 receptor inhibitors. We aimed to compare the effect of Ticagrelor and Clopidogrel in the treatment of patients post- ST-segment elevation myocardial infarction.
Methods: This study investigated PubMed, Scopus, Google Scholar Web of Science, and Embase Cochrane Library clinical trials.gov databases. Heterogeneity between studies was assessed using the I2 index and the Q statistic. The random effects model was used to combinestudies and the Funnel plot and Egger's test were used to assess the publication bias.
Results: Eleven studies were included in this meta-analysis. 5274 patients in the Ticagrelor and 5,295 patients in the Clopidogrel groups were examined. The mean age of the patients was 58.84 years (2.70) and 59.92 years (3.19)in the Ticagrelor and Clopidogrel groups, respectively. Based on the results of the meta-analysis, compared to Clopidogrel, Ticagrelor had decreased the outcomes of mortality, recurrent myocardial infarction, stroke, and MajorAdverse Cardiovascular Events (MACE). However, the post-myocardial infarction bleeding according to Bleeding Academic Research Consortium (BARC) criteria andreperfusion state regarding thrombolysis in myocardial infarction (TIMI) Flow Grading system showed no differences in both groups. However, these effects were not statistically significant.
Conclusions: Ticagrelor decreased thechance of mortality, re-infarction, stroke, and Major Adverse Cardiovascular Events in post- ST-segment elevation myocardial infarction patients compared to clopidogrel. But there was no difference in the chance of major bleedings (BARC ≥ 3) and improvement in thrombolysis in myocardial infarction grade flow between these two drugs. However, none of these findings were statistically significant, and more studies are needed to reach definitive results.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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