Sex differences in antiplatelet therapy: state-of-the art

Antiplatelet therapy is a cornerstone of secondary prevention of cardiovascular diseases (CVDs). However, current guidelines are based on data derived primarily from men, as women are generally underrepresented in trials. Consequently, there are insufficient and inconsistent data on the effect of antiplatelet drugs in women. Sex differences were reported in platelet reactivity, patient management, and clinical outcomes after treatment with aspirin, P2Y₁₂ inhibitor, or dual antiplatelet therapy. To evaluate whether sex-specific antiplatelet therapy is needed, in this review we discuss (i) how sex affects platelet biology and response to antiplatelet agents, (ii) how sex and gender differences translate into clinical challenges and (iii) how the cardiological care in women might be improved. Finally, we highlight the challenges faced in clinical practice regarding the different needs and characteristics of female and male patients with CVD and address issues requiring further investigation.

MicroRNAs in extracellular vesicles released from epicardial adipose tissue promote arrhythmogenic conduction slowing

Background

Patients with excess epicardial adipose tissue (EAT) are at increased risk of developing cardiac arrhythmias. EAT promotes arrhythmias by depolarizing the resting membrane of cardiomyocytes, which slows down conduction and facilitates re-entrant arrhythmias. We hypothesized that EAT slows conduction by secreting extracellular vesicles (EVs) and their microRNA (miRNA) cargo.

Objective

We aimed to determine the role of EAT-derived EVs and their miRNA cargo in conduction slowing.

Methods

EAT and subcutaneous adipose tissue (SAT) were collected from patients with atrial fibrillation. Adipose tissue explants were incubated in culture medium and secretome was collected. The numbers of EVs in the EAT and SAT secretome were measured by calibrated flow cytometry. EVs in the EAT secretome were isolated by size exclusion chromatography and miRNAs were sequenced. Pathway analysis was performed to predict candidates involved in cardiac electrophysiology. The candidates were validated in the EAT and SAT by quantitative real-time polymerase chain reaction. Finally, miRNA candidates were overexpressed in neonatal rat ventricular myocytes.

Results

The EV concentration was higher in the EAT secretome than in the SAT and control secretomes. miRNA sequencing of EAT-derived EVs detected a total of 824 miRNAs. Pathway analysis led to the identification of 7 miRNAs potentially involved in regulation of cardiac resting membrane potential. Validation of those miRNA candidates showed that they were all expressed in EAT, and that miR-1-3p and miR-133a-3p were upregulated in EAT in comparison with SAT. Overexpression of miR-1-3p and miR-133a-3p in neonatal rat ventricular myocytes led to conduction slowing and reduced Kcnj2 and Kcnj12 expression.

Conclusion

miR-1-3p and miR-133a-3p are potential mediators of EAT arrhythmogenicity.

Diagnostic value of soluble urokinase-type plasminogen activator receptor in patients with acute coronary syndrome: A systematic review and meta-analysis

BACKGROUND

In contemporary clinical practice, there is an increasing need for new clinically relevant biomarkers potentially optimizing management strategies in patients with suspected acute coronary syndrome (ACS). This study aimed to determine the diagnostic utility of soluble urokinase-type plasminogen activator receptor (suPAR) levels in individuals with suspected ACS.

METHODS

A literature search was performed in Web of Science, PubMed, Scopus, and the Cochrane Central Register of Controlled Trials databases, for studies comparing suPAR levels among patients with and without ACS groups. The methodological quality of the included papers was assessed using the Newcastle-Ottawa Scale (NOS). A fixed-effects model was used if I² < 50%; otherwise, the random-effects model was performed.

RESULTS

Five studies with 3417 participants were included in the meta-analysis. Pooled analysis showed that mean suPAR levels in the ACS group were statistically significantly higher than in the control group (3.56 ± 1.38 vs. 2.78 ± 0.54 ng/mL, respectively; mean difference: 1.04; 95% confidence interval: 0.64-1.44; I² = 99%; p < 0.001).

CONCLUSIONS

In the context of acute coronary syndrome, suPAR is a potential biomarker for the early identification of medical conditions in individuals who are being treated in emergency rooms.

In-Hospital Outcomes and Conditions Associated With Coronary Artery Aneurysms in Chronic Coronary Syndrome

BACKGROUND

Coronary artery aneurysms (CAA) are infrequent findings among patients undergoing coronary angiography and may be associated with systemic diseases.

METHODS

We analyzed the National Inpatient Sample database from 2016 to 2020 by including all patients with the admission diagnosis of the chronic coronary syndrome (CCS). We sought to determine the impact of CAA on in-hospital outcomes encompassing all-cause death, bleeding, cardiovascular complications, and stroke. Secondly, we examined the association of CAA with other relevant systemic conditions.

RESULTS

The presence of CAA was associated with a 3-fold increase in the odds of cardiovascular complications (OR 3.1, 95 % CI 2.9-3.8), however, it was associated with reduced odds of stroke (OR 0.7, 95 % CI 0.6-0.9). There was no significant impact on all-cause death and overall bleeding complications, although there appeared to be a reduction in the odds of gastrointestinal (GI) bleeding associated with CAA (OR 0.6, 95 % CI 0.4-0.8). Patients with CAA vs. those without CAA had a significantly greater prevalence of extracoronary arterial aneurysms (7.9 % vs. 1.4 %), systemic inflammatory disorders (6.5 % vs. 1.1 %), connective tissue disease (1.6 % vs. 0.6 %), coronary artery dissection (1.3 % vs. 0.1 %), bicuspid aortic valve (0.8 % vs. 0.2 %), and extracoronary arterial dissection (0.3 % vs. 0.1 %). In the multivariable regression, systemic inflammatory disorders, extracoronary aneurysms, coronary artery dissection, and connective tissue diseases were independent predictors of CAA.

CONCLUSIONS

CAA in patients with CCS is associated with greater odds of cardiovascular complications during hospitalization. These patients also had a substantially greater prevalence of extracardiac vascular and systemic abnormalities.

A comprehensive review and meta-analysis of suPAR as a predictor of acute kidney injury

INTRODUCTION AND OBJECTIVE

The global impact of acute kidney injury (AKI) has not been thoroughly investigated. With the development of new techniques, soluble urokinase plasminogen activator receptor (suPAR) has become increasingly important in the diagnosis of AKI. Therefore, a systematic review and meta-analysis was carried out to evaluate the predictive value of suPAR for AKI.

MATERIAL AND METHODS

The review and meta-analysis investigated the relationship between suPAR levels and acute kidney injury. Pubmed, Scopus, Cochrane Controlled Register of Trials, and Embase were searched for relevant studies from inception to 10 January 2023. Stata (Ver. 16 StataCorp, College Station, TX, USA) was used for all statistical analyses. A random effects model using the Mantel-Haenszel approach was employed, and odds ratios (OR) and standard mean differences (SMD) with 95% confidence intervals (CI) were calculated for binary and continuous outcomes, respectively.

RESULTS

Nine studies reported suPAR levels among patients with and without AKI. Pooled analysis showed that suPAR levels in patients with and without AKI varied and amounted to 5.23 ± 4.07 vs. 3.23 ±0.67 ng/mL (SMD = 3.19; 95%CI: 2.73 to 3.65; p<0.001). The results from the sensitivity analysis did not alter the direction.

CONCLUSIONS

This results show that increasing suPAR levels are associated with the occurrence of AKI. SuPAR might act as a novel biomarker for CI-AKI in clinical practice.

Severe Acute Thrombocytopenia After Treatment with Tirofiban: A Case Series Approach

Glycoprotein IIb/IIIa inhibitors are an adjuvant therapy for the treatment of patients with acute coronary syndromes. The main adverse reactions are bleeding and thrombocytopenia in 1-2% of cases. A 66-year-old woman arrived at the emergency department with ST-elevation MI. The catheterisation lab was busy, so she received thrombolytic therapy. Coronary angiography revealed a 90% stenosis in the middle segment of the left anterior descending artery and Thrombolysis in MI 2 flow. Subsequent percutaneous coronary intervention showed abundant thrombus and a coronary dissection and it was necessary to insert five drug-eluting stents. Non-fractionated heparin and a tirofiban infusion were used. After the percutaneous coronary intervention, she developed severe thrombocytopenia, haematuria and gingivorrhagia, for which infusion of tirofiban was suspended. In follow-up, no major bleeding or subsequent haemorrhagic complications were identified. It is crucial to distinguish between heparin-induced thrombocytopenia and thrombocytopenia caused by other drugs. A high level of suspicion should be employed in these cases.

Prediction value of soluble urokinase plasminogen activator receptor (suPAR) in COVID-19 patients - a systematic review and meta-analysis

INTRODUCTION AND OBJECTIVE

In COVID-19, the rapid prediction of the severity of a patient's condition using modern biomarkers can accelerate the implementation of appropriate therapy, and thus improve the patient's prognosis.

MATERIAL AND METHODS

A meta-analysis was conducted of data available in the literature on the differences in baseline suPAR blood concentration between patients (1) who tested positive and negative for COVID-19, (2) who had severe and non-severe COVID-19, and (3) COVID-19 survivors and non-survivors.

RESULTS

SuPAR levels in SARS-CoV-2 negative and positive patients varied and amounted to 3.61±1.59 ng/ml vs. 6.45±3.13 ng/ml, respectively (MD = -3.18; 95%CI: -4.71 to -1.66; p<0.001). suPAR levels among non-severe and severe COVID-19 patients were 7.06±2.64 ng/ml and 5.06±3.16 ng/ml (MD = 0.18; 95%CI: -2.48 to 2.83; p=0.90), respectively. Pooled analysis showed that suPAR levels between severe versus critical COVID-19 patients to be 5.59±1.54 ng/ml and 6.49±1.43 ng/ml, respectively (MD = -1.00; 95%CI: -1.31 to -0.70; p<0.001). The suPAR levels between ICU survivors versus non-survivors amounted to 5.82±2.33 ng/ml and 8.43±4.66 ng/ml (MD = -3.59; 95%CI: -6.19 to -1.00; p=0.007). In the case of in-hospital mortality, the mean suPAR level among survivors to hospital discharge was 5.63±1.27 ng/ml, compared to 7.85±2.61 ng/ml for patients who did not survive (MD = -3.58; 95%CI: -5.42 to -1.74; p<0.001).

CONCLUSIONS

SuPAR levels are significantly elevated in severe COVID-19 illness and maybe useful in predicting mortality. Further studies are needed to determine cut-off points and clarify the association of suPAR levels with disease progression. This is of utmost importance given the ongoing pandemic and overburdened health care systems.

Outcomes of audio-instructed and video-instructed dispatcher-assisted cardiopulmonary resuscitation: a systematic review and meta-analysis

BACKGROUND

The present meta-analysis of clinical and simulation trials aimed to compare video-instructed dispatcher-assisted bystander cardiopulmonary resuscitation (V-DACPR) with conventional audio-instructed dispatcher-assisted bystander cardiopulmonary resuscitation (C-DACPR).

METHODS

We searched PubMed, Embase, Web of Science, Cochrane Collaboration databases and Scopus from inception until June 10, 2021. The primary outcomes were the prehospital return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with a good neurological outcome for clinical trials, and chest compression quality for simulation trials. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) indicated the pooled effect. The analyses were performed with the RevMan 5.4 and STATA 14 software.

RESULTS

Overall, 2 clinical and 8 simulation trials were included in this meta-analysis. In clinical trials, C-DACPR and V-DACPR were characterised by, respectively, 11.8% vs. 24.3% of prehospital ROSC (OR = 0.46; 95% CI: 0.30, 0.69; I² = 66%; p < .001), 10.7% vs. 22.3% of survival to hospital discharge (OR = 0.46; 95% CI: 0.30, 0.70; I² = 69%; p < .001), and 6.3% vs. 16.0% of survival to hospital discharge with a good neurological outcome (OR = 0.39; 95% CI: 0.23, 0.67; I² = 73%; p < .001). In simulation trials, chest compression rate per minute equalled 91.3 ± 22.6 for C-DACPR and 107.8 ± 12.6 for V-DACPR (MD = -13.40; 95% CI: -21.86, -4.95; I² = 97%; p = .002). The respective values for chest compression depth were 38.7 ± 14.3 and 41.8 ± 12.5 mm (MD = -2.67; 95% CI: -8.35, 3.01; I² = 98%; p = .36).

CONCLUSIONS

As compared with C-DACPR, V-DACPR significantly increased prehospital ROSC and survival to hospital discharge. Under simulated resuscitation conditions, V-DACPR exhibited a higher rate of adequate chest compressions than C-DACPR.Key messagesBystander cardiopulmonary resuscitation parameters significantly depend on the dispatcher's support and the manner of the support provided.Video-instructed dispatcher-assisted bystander cardiopulmonary resuscitation can increase the rate of prehospital return of spontaneous circulation and survival to hospital discharge.Video-instructed dispatcher-assisted bystander cardiopulmonary resuscitation improves the quality of chest compressions compared with dispatcher-assisted resuscitation without video instruction.

Removal of platelets from blood plasma to improve the quality of extracellular vesicle research

BACKGROUND

Blood plasma is commonly used for biomarker research of extracellular vesicles (EVs). Removing all cells prior to analysis of EVs is essential.

OBJECTIVES

We therefore studied the efficacy of the most commonly used centrifugation protocol to prepare cell-free plasma.

METHODS

Plasma was prepared according to the double centrifugation protocol of the International Society on Thrombosis and Haemostasis (ISTH) in three independent studies. The concentrations of platelets, platelet-derived EVs, and erythrocyte-derived EVs were measured by calibrated flow cytometry.

RESULTS

The mean platelet concentration ranged from 5.1 × 105 /ml to 2.8 × 107 /ml and differed 55-fold between studies. Thus, the ISTH centrifugation protocol does not remove all platelets and results in variation between studies. As the concentration of platelet-derived EVs and platelets correlates linearly (R2  = .56), and the volume fraction of EVs and platelets in plasma are similar, the presence of platelets affects downstream analysis. To remove platelets a 0.8-μm polycarbonate filter was used to lower the platelet concentration 146-fold (p = .0013), without affecting the concentration of platelet-derived and erythrocyte-derived EVs (p = .982, p = .742).

CONCLUSIONS

To improve the quality of EV research, we recommend (1) measuring and reporting the platelet concentration in plasma used for EV research, or (2) removing platelets by centrifugation followed by filtration.

Should targeted temperature management be used in cardiogenic shock patients? Systematic review and meta-analysis

BACKGROUND

Therapeutic hypothermia, or targeted temperature management (TTM), is a strategy of reducing the core body temperature of survivors of sudden cardiac arrest, cardiogenic shock (CS) or stroke. Therefore, a systematic literature review and meta-analysis were performed to tackle the question about whether the implementation of TTM is actually beneficial for patients with CS.

METHODS

Study was designed as a systematic review and meta-analysis. PubMed, Cochrane Library, Web of Science and Scopus were searched from these databases inception to July 17, 2022. Eligible studies were those comparing TTM and non-TTM treatment in CS patients. Data were pooled with the Mantel-Haenszel method.

RESULTS

Thirty-day mortality was reported in 3 studies. Polled analysis of 30-day mortality was 44.2% for TTM group and 48.9% for non-TTM group (risk ratio: 0.90; 95% confidence interval: 0.75 to 1.08; p = 0.27). Other mortality follow-up periods showed also no statistically significant differences (p > 0.05). The occurrence of adverse events in the studied groups also did not show statistically significant differences between TTM and non-TTM groups (p > 0.05 for myocardial infarction, stent thrombosis, sepsis, pneumonia, stroke or bleeding events).

CONCLUSIONS

The present analysis shows no significant benefit of TTM in patients with CS. Moreover, no statistically significant increase of the incidence of adverse effects was found. However, further randomized studies with higher sample size and greater validity are needed to determine if TTM is worth implementing in CS patients.

Platelet extracellular vesicles are superior to cardiac troponin to diagnose acute coronary syndrome with short symptom duration: LEMONADE trial

Background

Acute coronary syndrome (ACS), which comprises acute myocardial infarction (AMI) and unstable angina pectoris (UAP), is one of the main causes of mortality worldwide. Cardiac troponin is the gold standard to diagnose AMI. Troponin has two main disadvantages: it is negative in patients with UAP but positive in other diseases. During ACS, activated platelets release extracellular vesicles (EVs), which promote coagulation and associate with fibrin, and contribute to thrombus formation. We hypothesized that the concentration and composition of circulating platelet EVs (1) change in blood of patients with ACS compared to patients with other causes of chest pain, and (2) thereby allow earlier diagnosis of ACS than cardiac troponin.

Purpose

We aimed to determine the diagnostic value of circulating platelet EVs as novel early biomarkers of developing ACS.

Methods

We conducted a prospective, multicentre trial enrolling 105 patients who presented to the emergency department with suspected ACS. Blood was collected at admission to measure the concentration of EVs and cardiac troponin. Flow cytometry (Apogee A60-Micro) was used to determine plasma concentrations of platelet EVs exposing P-selectin (CD61+/CD62p+) and fibrin (CD61+/fibrin+).

Results

Plasma concentrations of platelet EVs exposing fibrin was lower in patients with ACS, compared to patients with other causes of chest pain (p=0.023) and lower in patients with an occlusive thrombus compared to non-occlusive plaque (p=0.015). Fibrin exposing-EVs were independent predictors of ACS (OR 8.2, CI 1.3–16.4) in multivariate analysis, allowing to diagnose ACS with 75% sensitivity and 72% specificity. Among patients with pain onset less than 2 hours before presentation, fibrin-exposing EVs had substantially better diagnostic performance than troponin (area under the ROC curve 0.90 vs. 0.74, respectively). Regarding other causes of chest pain, fibrin-exposing EVs were the lowest in patients with ACS, higher in patients with other cardiological causes of chest pain, and the highest in patients with non-cardiological causes of chest pain (p=0.036).

Conclusions

Circulating fibrin-exposing EVs are early biomarkers of developing ACS, superior to cardiac troponin in patients with pain onset less than 2 hours before presentation. Incorporation of EV measurements into the ACS diagnostic algorithm might revolutionise thrombotic risk stratification in the emergency setting.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Specialised Research Fellowship, “Club 30” of the Polish Society of Cardiology

Diagnostic ability of miR-19a and Let-7f along with platelet and leukocyte extracellular vesicles in acute ischemic stroke patients

Background

Ischemic stroke (IS) is one of the most frequent causes of death. Since miRNAs have been illustrated to play an important role in various processes through regulation of multiple genes, and platelet function, their utility as novel biomarkers should be determined.

Purpose

We aimed to analyze the circulating platelet-derived miR-19a-3p, miR-186-5p, Let-7f, platelet-extracellular vesicles (EVs), leukocyte-EVs, and endothelial-EVs levels 24-h and 7-days after IS as novel diagnostic and prognostic/predictive biomarkers in 28 acute IS and 35 control patients.

Methods

Blood samples of 28 patients diagnosed with acute IS with hyper platelet reactivity were collected 24-h and 7-days after stroke and 35 age- and gender-matched individuals free of stroke with multiple risk factors for cardiovascular disease. Platelet reactivity was assessed by AA-, TRAP-, ADP-induced platelet aggregometry. PlasmaRNA was extracted; quality RNA was assessed: fluorometric assay; RT-PCR for miRNAs expression measurement and flow-cytometry for EVs determination p&lt;0.05.

Results

Patients with IS on day-1 had significantly higher platelet reactivity assessed by AA-induced platelet aggregometry compared to controls (p=0.001). Patients with normal platelet activation had significantly higher miR-186-5p expression levels compared to patients with HPR at day-1 acute-stroke (p=0.034). Seven days after acute stroke, expression levels of miR-186-5p significantly decreased in the same patients with normal platelet reactivity (p=0.036). Patients with HPR had significantly elevated platelet-EVs (CD62) concentration compared to patients with normal platelet reactivity at the day of 1 acute-stroke (p=0.012). Similarly, patients with HPR had significantly higher leukocyte-EVs (CD45) concentration compared to patients with normal platelet function at day-1 acute-stroke (p=0.002). Diagnostic values of baseline miRNAs and EVs were evaluated with receiver operating characteristic curve analysis. ROC curve showed that pooling the miR-19a-3p expressions, platelet-EVs, and leukocyte-EVs concentration yielded a higher AUC than the value of each individual biomarker as AUC was 0.893 (95% CI, 0.79–0.99). Patients with moderate stroke had significantly elevated miR-19a-3p expression levels compared with patients with minor stroke at the day of acute IS. AUC in ROC curve analysis was 0.867, (95% CI, 0.74–0.10) p=0.001.

Conclusions

Our analysis showed alteration of circulating miRNAs and EVs after IS. Combination of miR-19a-3p, Let-7f, platelet-EVs and leukocyte-EVs might have a diagnostic value for acute stroke and miR-19a-3p can predict the severity of stroke in IS patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Science Centre - Narodowe Centrum Nauki

Leukocyte extracellular vesicles as the first biomarkers to predict outcomes in patients undergoing percutaneous aortic valve replacement

Background

Transcatheter aortic valve implantation (TAVI) is a novel treatment for aortic stenosis (AS), associated with better outcomes than surgical aortic valve replacement in high-risk patients. However, up to 29% of patients annually experience major adverse cardiac and cerebrovascular events (MACCE) after TAVI. MACCE are mostly caused by atherothrombosis, i.e. formation of platelet aggregates (thrombi) on ruptured atherosclerotic plaques. Because platelets release extracellular vesicles (EVs) during thrombus formation, we hypothesized that EVs are a biomarker to predict MACCE after TAVI.

Methods

This was a multicentre, prospective clinical study. Venous blood was collected 1 day before TAVI and at hospital discharge (n=57, mean age 79.9+6.4 years, 49% male). Flow cytometry (Apogee A60-Micro) was used to determine concentrations of plasma EVs labelled with markers for endothelial cells (CD146), leukocytes (CD45), platelets and megakaryocytes (CD61) and activated platelets (CD62p). Analysis of flow cytometry data files was fully automated. Rosetta Calibration (Exometry) and Flow-SR were used for diameter and refractive index determination. Wilcoxon signed rank test was used to compare EV concentrations before and after TAVI. The predictive value of EVs for MACCE and the cut-offs were calculated using a receiver operating characteristic curve. Logistic regression model incorporating EV concentrations and clinical characteristics was used to determine the best model for MACCE prediction.

Results

Concentrations of EVs from activated platelets increased, whereas from leukocytes decreased after TAVI, compared to the measurement before (p=0.06, p=0.04, respectively). Among 55 patients discharged from the hospital, 14 patients experienced MACCE (25%) during the median 15 months of observation. Increased baseline concentration of leukocyte EVs and male gender were the only independent predictors of MACCE in multivariable analysis (OR 4.01, 95% CI 0.77–23.77, p=0.04 for leukocyte EVs; OR 6.84, 95% CI 1.41–33.17, p=0.03 for male gender).

Conclusions

We identified increased concentrations of leukocyte EVs as new candidate biomarkers to predict MACCE after TAVI. Leukocyte EVs could be used to augment risk stratification in this patient cohort. The next step is to validate the clinical applicability of EVs to predict post-TAVI MACCE in a large-scale clinical trial.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Young Investigator Grant of the Polish Society of Cardiology

Role of copeptin in diagnosis and outcome prediction in patients with heart failure: a systematic review and meta-analysis

Introduction: This systematic review and meta-analysis of 19 studies, was conducted to evaluate the role of copeptin in diagnosis and outcome prediction in HF patients. Materials and Methods: A systematic literature search for clinical trials reporting copeptin levels in HF patients was performed using EMBASE, PubMed, Cochrane Register of Controlled Trials, and Google Scholar. Articles from databases published by January 2nd, 2022, that met the selection criteria were retrieved and reviewed. The random effects model was used for analyses. Results: Pooled analysis found higher mean copeptin levels in HF vs. non-HF populations (43.6 ± 46.4 vs. 21.4 ± 21.4; MD= 20.48; 95%CI: 9.22 to 31.74; p < 0.001). Pooled analysis of copeptin concentrations stratified by ejection fraction showed higher concentrations in HFrEF vs. HFpEF (17.4 ± 7.1 vs. 10.1 ± 5.5; MD= -4.69; 95%CI: -7.58 to -1.81; p = 0.001). Copeptin level was higher in patients with mortality/acute HF-related hospitalization vs. stable patients (31.3 ± 23.7 vs. 20.4 ± 12.8; MD= -13.06; 95%CI: -25.28 to -0.84; p = 0.04). Higher copeptin concentrations were associated with mortality and observed in all follow-up periods (p <0.05). Discussion and Conclusions: Present meta-analysis showed that elevated copeptin plasma concentrations observed in HF patients are associated with increased risk of all-cause mortality, thus copeptin may serve as predictor of outcome in HF.

Catheter-directed therapy to treat intermediate- and high-risk pulmonary embolism: Personal experience and review of the literature

Pulmonary embolism (PE) is the third leading cause of cardiovascular death in the western world. Prompt recognition, risk stratification, and individualized treatment are crucial to improve outcomes in patients with PE. Anticoagulation alone is a sufficient therapeutic option in low-risk patients, whereas primary reperfusion with systemic thrombolysis (ST) is usually chosen in high-risk patients. The choice of treatment in intermediate-risk patients is complex and depends on the clinical presentation. Catheter-directed therapy (CDTh) includes all therapies delivered via a catheter placed in the branches of the pulmonary arteries directly into the thrombus. Because ST bears a high risk of major bleeding and numerous patients have contraindications to ST, CDTh is an alternative to ST in intermediate- and high-risk PE patients. CDTh includes local thrombolysis using low-dose alteplase, ultrasound-assisted thrombolysis, and mechanical fragmentation and aspiration of the thrombi, as well as their combinations. In this review article, we have summarized devices and technical details for CDTh, discussed the efficacy and safety of CDTh in comparison to ST in previous clinical trials, and outlined future research directions regarding CDTh, both based on the literature and our personal experience from the local PE Response Team of the Center for the Management of Pulmonary Embolism (CELZAT) in Warsaw.

Platelet function changes in patients undergoing endovascular aortic aneurysm repair: Review of the literature

Patients with abdominal aortic aneurysm (AAA) have a higher risk of cardiovascular (CV) events, which seems to be associated with disturbed platelet (PLT) function. Endovascular aneurysm repair (EVAR) is an emerging, less-invasive treatment alternative to surgical AAA repair. Both platelet function abnormalities in patients with AAA and the effect of EVAR on platelet function are poorly understood. In this review, we aim to fill the gap regarding the effect of EVAR on PLT function in AAA patients by discussing PLT function disturbances in patients with AAA, PLT function changes after EVAR, evidence from clinical studies regarding PLT function before and after EVAR, and antiplatelet or and antithrombotic treatment in patients undergoing EVAR. The goal of our review is to summarize the contemporary knowledge and initiate further studies to better understand PLT function changes in patients undergoing EVAR, optimize the pharmacotherapy before and after EVAR and further improve outcomes in this group of patients.

Association Between the Expression of MicroRNA-125b and Survival in Patients With Acute Coronary Syndrome and Coronary Multivessel Disease

Background

MicroRNAs (miRNA, miR) have an undeniable physiological and pathophysiological significance and act as promising novel biomarkers. The aim of the study was to investigate blood-derived miRNAs and their association with long-term all-cause mortality in patients with multivessel disease (MVD) suffering from acute coronary syndrome (ACS).

Materials and Methods

This study was an observational prospective study, which included 90 patients with MVD and ACS. Expression of miR-125a, miR-125b, and miR-223 was analysed by polymerase chain reaction (PCR). Patients were followed-up for a median of 7.5 years. All-cause mortality was considered as the primary endpoint. Adjusted Cox-regression analysis was performed for prediction of events.

Results

Elevated expression of miR-125b (&gt;4.6) at the time-point of ACS was associated with increased long-term all-cause mortality (adjusted [adj.] hazard ratio [HR] = 11.26, 95% confidence interval [95% CI]: 1.15–110.38; p = 0.038). The receiver operating characteristic (ROC) analysis showed a satisfactory c-statistics for miR-125b for the prediction of long-term all-cause mortality (area under the curve [AUC] = 0.76, 95% CI: 0.61–0.91; p = 0.034; the negative predictive value of 98%). Kaplan–Meier time to event analysis confirmed an early separation of the survival curves between patients with high vs low expression of miR-125b (p = 0.003). An increased expression of miR-125a and miR-223 was found in patients with non-ST-segment elevation ACS (NSTE-ACS) as compared to those with ST-segment elevation myocardial infarction (STEMI) (p = 0.043 and p = 0.049, respectively) with no difference in the expression of miR-125b between the type of ACS.

Conclusion

In this hypothesis generating study, lower values of miR-125b were related to improved long-term survival in patients with ACS and MVD. Larger studies are needed to investigate whether miR-125b can be used as a suitable predictor for long-term all-cause mortality.

Long-Term Mortality After TAVI for Bicuspid vs. Tricuspid Aortic Stenosis: A Propensity-Matched Multicentre Cohort Study

Objectives

Patients with bicuspid aortic valve (BAV) stenosis were excluded from the pivotal trials of transcatheter aortic valve implantation (TAVI). We compared the in-hospital and long-term outcomes between patients undergoing TAVI for bicuspid and tricuspid aortic valve (TAV) stenosis.

Methods

We performed a retrospective registry-based analysis on patients who underwent TAVI for BAV and TAV at five different centers between January 2009 and August 2017. The primary outcome was long-term all-cause mortality. Secondary outcomes were in-hospital mortality, procedural complications, and valve performance.

Results

Of 1,451 consecutive patients who underwent TAVI, two propensity-matched cohorts consisting of 130 patients with BAV and 390 patients with TAV were analyzed. All-cause mortality was comparable in both groups up to 10 years following TAVI (HR 1.09, 95% CI: 0.77–1.51). Device success and in-hospital mortality were comparable between the groups (96 vs. 95%, p = 0.554 and 2.3 vs. 2.1%, p = 0.863, respectively). Incidence of procedural complications was similar in both groups, with a trend toward a higher rate of stroke in patients with BAV (5 vs. 2%, p = 0.078). Incidence of moderate or severe paravalvular leak (PVL) at discharge was comparable in both groups (2 vs. 2%, p = 0.846). Among patients with BAV, all-cause mortality was similar in self-expanding and balloon-expandable prostheses (HR 1.02, 95% CI: 0.52–1.99) and lower in new-generation devices compared to old-generation valves (HR 0.27, 95% CI 0.12–0.62).

Conclusion

Patients who had undergone TAVI for BAV had comparable mortality to patients with TAV up to 10 years after the procedure. The device success, in-hospital mortality, procedural complications, and PVL rate were comparable between the groups. The high rate of neurological complications (5%) in patients with BAV warrants further investigation.

The diagnostic and prognostic value of copeptin in patients with acute ischemic stroke and transient ischemic attack: A systematic review and meta-analysis

Background

Stroke is the second main cause of mortality and the third leading cause of mortality and permanent disability combined. Many potential biomarkers have been described to contribute to the diagnosis, prognosis of outcomes, and risk stratification after stroke. Copeptin is an inactive peptide that is produced in an equimolar ratio to arginine vasopressin in response to the activation of the endogenous stress system.

Methods

The present study is a systematic review and meta-analysis to assess plasma copeptin concentrations, diagnostic and prognostic values for risk stratification after acute ischemic stroke and transient ischemic attack.

Results

Mean copeptin level in stroke vs. non-stroke groups varied and amounted to 19.8 ± 17.4 vs. 9.7 ± 6.6 pmol/L, respectively (mean differences [MD]: 12.75; 95% confidence interval [CI]: 5.00 to 20.49; p < 0.001), in good vs. poor outcome 12.0 ± 3.6 vs. 29.4 ± 14.5 (MD: −8.13; 95% CI: −8.37 to −7.88; p < 0.001) and in survive vs. non-survive stroke patients: 13.4 ± 3.2 vs. 33.0 ± 12.3, respectively (MD: −13.43; 95% CI: −17.82 to −9.05; p < 0.001).

Conclusions

The above systematic review and meta-analysis suggests that monitoring the copeptin levels may help predict the long-term prognosis of ischemic stroke efficiently. Determining the copeptin level may help individualize the management of ischemic stroke patients, keep stroke risk lower, reduce post-stroke complications, including patient death, and minimize healthcare costs.

Statins and the risk of pancreatic cancer: A systematic review and meta-analysis of 2,797,186 patients

BACKGROUND

Statin use in many studies is related to the improvement of a patients' condition including reducing the risk of various malignancies. Herein, is a systematic review and meta-analysis to examine the evidence on the association between statin therapy and the risk of the occurrence of pancreatic cancer, mainly in terms of decreased risk of developing pancreatic cancer among patients using statin therapy in the long-term perspective.

METHODS

PubMed, Web of Science, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from database inception to December 1st, 2021. Random effect models were used to estimate summary odds ratios (OR) and the corresponding 95% confidence intervals (CI).

RESULTS

A total of 26 studies comprising 2,797,186 patients were included. Polled analysis showed that pancreatic cancer occurrence in statin vs. no-statin group varied and amounted to 0.4% vs. 0.6% (RR = 0.83; 95% CI: 0.72-0.96; I² = 84%; p = 0.01).

CONCLUSIONS

In summary, the present analysis shows that overall statins use is significantly associated with a reduction in risk of pancreatic cancer. However, these results were not confirmed for the randomized controlled trial subgroup. Further prospective studies are needed to confirm the current results.

Performance of Copeptin for Early Diagnosis of Acute Coronary Syndromes: A Systematic Review and Meta-Analysis of 14,139 Patients

Diagnosis of acute coronary syndrome (ACS) based on copeptin level may enable one to confirm or rule-out acute myocardial infarction (AMI) with higher sensitivity and specificity, which may in turn further reduce mortality rate and decrease the economic costs of ACS treatment. We conducted a systematic review and meta-analysis to investigate the relationship between copeptin levels and type of ACS. We searched Scopus, PubMed, Web of Science, Embase, and Cochrane to locate all articles published up to 10 October 2021. We evaluated a meta-analysis with random-effects models to evaluate differences in copeptin levels. A total of 14,139 patients (4565 with ACS) were included from twenty-seven studies. Copeptin levels in AMI and non-AMI groups varied and amounted to 68.7 ± 74.7 versus 14.8 ± 19.9 pmol/L (SMD = 2.63; 95% CI: 2.02 to 3.24; p < 0.001). Copeptin levels in the AMI group was higher than in the unstable angina (UAP) group, at 51.9 ± 52.5 versus 12.8 ± 19.7 pmol/L (SMD = 1.53; 95% CI: 0.86 to 2.20; p < 0.001). Copeptin levels in ST-elevation myocardial infarction (STEMI) versus non-ST elevation myocardial infarction (NSTEMI) patient groups were 54.8 ± 53.0 versus 28.7 ± 46.8 pmol/L, respectively (SMD = 1.69; 95% CI: = 0.70 to 4.09; p = 0.17). In summary, elevated copeptin levels were observed in patients with ACS compared with patients without ACS. Given its clinical value, copeptin levels may be included in the assessment of patients with ACS as well as for the initial differentiation of ACS.

Impact of COVID-19 on in-hospital cardiac arrest outcomes: An updated meta-analysis

BACKGROUND

The main purposes of this meta-analysis are to update the information about the impact of coronavirus disease 2019 (COVID-19) pandemic on outcomes of in-hospital cardiac arrest (IHCA) and to investigate the impact of being infected by by severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) on IHCA outcomes.

METHODS

The current meta-analysis is an update and follows the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

In analyses, pre- and intra-COVID-19 periods were observed for: shockable rhythms in 17.6% vs. 16.2% (odds ratio [OR]: 1.11; 95% confidence interval [CI]: 0.71-1.72; p = 0.65), return of spontaneous circulation (ROSC) in 47.4% vs. 44.0% (OR: 1.36; 95% CI: 0.90-2.07; p = 0.15), 30-day mortality in 59.8% vs. 60.9% (OR: 0.95; 95% CI: 0.75-1.22; p = 0.69) and overall mortality 75.8% vs. 74.7% (OR: 0.80; 95% CI: 0.49-1.28; p = 0.35), respectively. In analyses, SARS-CoV-2 positive and negative patients were observed for: shockable rhythms in 9.6% vs. 19.8% (OR: 0.51; 95% CI: 0.35-0.73; p < 0.001), ROSC in 33.9% vs. 52.1% (OR: 0.47; 95% CI: 0.30-0.73; p < 0.001), 30-day mortality in 77.2% vs. 59.7% (OR: 2.08; 95% CI: 1.28-3.38; p = 0.003) and overall mortality in 94.9% vs. 76.7% (OR: 3.20; 95% CI: 0.98-10.49; p = 0.05), respectively.

CONCLUSIONS

Despite ROSC, 30-day and overall mortality rate were not statistically different in pre- vs. intra-COVID-19 periods, a lower incidence of ROSC and higher 20-day mortality rate were observed in SARS-CoV-2 (+) compared to SARS-CoV-2 (-) patients.

Outcomes and mortality associated with atrial arrhythmias among patients hospitalized with COVID-19: A systematic review and meta-analysis

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. Herein, is a systematic review with meta-analysis to determine the impact of AF/atrial flutter (AFL) on mortality, as well as individual complications in patients hospitalized with the coronavirus disease 2019 (COVID-19).

Methods

A systematic search of the SCOPUS, Medline, Web of Science, CINAHL and Cochrane databases was performed. The a priori primary outcome of interest was in-hospital mortality. A random-effects model was used to pool study results.

Results

Nineteen studies which included 33,296 patients were involved in this meta-analysis. In-hospital mortality for AF/AFL vs. no-AF/AFL groups varied and amounted to 32.8% vs. 14.2%, respectively (risk ratio [RR]: 2.18; 95% confidence interval [CI]: 1.79–2.65; p < 0.001). In-hospital mortality in new onset AF/AFL compared to no-AFAFL was 22.0% vs. 18.8% (RR: 1.86; 95% CI: 1.54–2.24; p < 0.001). Intensive care unit (ICU) admission was required for 17.7% of patients with AF/AFL compared to 10.8% for patients without AF/AFL (RR: 1.94; 95% CI: 1.04–3.62; p = 0.04).

Conclusions

The present study reveals that AF/AFL is associated with increased in-hospital mortality and worse outcomes in patients with COVID-19 and may be used as a negative prognostic factor in these patients. Patients with AF/AFL are at higher risk of hospitalization in ICU. The presence of AF/AFL in individuals with COVID-19 is associated with higher risk of complications, such as bleeding, acute kidney injury and heart failure. AF/AFL may be associated with unfavorable outcomes due to the hemodynamic compromise of cardiac function itself or hyperinflammatory state typical of these conditions.

The Influence of COVID-19 on Out-Hospital Cardiac Arrest Survival Outcomes: An Updated Systematic Review and Meta-Analysis

Cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest (OHCA) is associated with poor prognosis. Because the COVID-19 pandemic may have impacted mortality and morbidity, both on an individual level and the health care system as a whole, our purpose was to determine rates of OHCA survival since the onset of the SARS-CoV2 pandemic. We conducted a systematic review and meta-analysis to evaluate the influence of COVID-19 on OHCA survival outcomes according to the PRISMA guidelines. We searched the literature using PubMed, Scopus, Web of Science and Cochrane Central Register for Controlled Trials databases from inception to September 2021 and identified 1775 potentially relevant studies, of which thirty-one articles totaling 88,188 patients were included in this meta-analysis. Prehospital return of spontaneous circulation (ROSC) in pre-COVID-19 and COVID-19 periods was 12.3% vs. 8.9%, respectively (OR = 1.40; 95%CI: 1.06-1.87; p < 0.001). Survival to hospital discharge in pre- vs. intra-COVID-19 periods was 11.5% vs. 8.2% (OR = 1.57; 95%CI: 1.37-1.79; p < 0.001). A similar dependency was observed in the case of survival to hospital discharge with the Cerebral Performance Category (CPC) 1-2 (6.7% vs. 4.0%; OR = 1.71; 95%CI: 1.35-2.15; p < 0.001), as well as in the 30-day survival rate (9.2% vs. 6.4%; OR = 1.63; 95%CI: 1.13-2.36; p = 0.009). In conclusion, prognosis of OHCA is usually poor and even worse during COVID-19.

Vitamin D supplementation to treat SARS-CoV-2 positive patients. Evidence from meta-analysis

BACKGROUND

Vitamin D is a likely candidate for treatment as its immune modulating characteristics have effects on coronavirus disease 2019 (COVID-19) patients. It was sought herein, to summarize the studies published to date regarding the vitamin D supplementation to treat severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive patients.

METHODS

A systematic review and meta-analysis were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary outcome were 14-day and in-hospital mortality reported as an odds ratio (OR) with the associated 95% confidence interval (CI).

RESULTS

Eight articles were included in the review with a combined total of 2,322 individual patients, 786 in the vitamin D supplementation group and 1,536 in the control group. The use of vitamin D compared to the group without vitamin D supplementation was associated with a lower 14-day mortality (18.8% vs. 31.3%, respectively; OR = 0.51; 95% CI: 0.12-2.19; p = 0.36), a lower in-hospital mortality (5.6% vs. 16.1%; OR = 0.56; 95% CI: 0.23-1.37; I2 = 74%; p = 0.20), the rarer intensive care unit admission (6.4% vs. 23.4%; OR = 0.19; 95% CI: 0.06-0.54; I2 = 77%; p = 0.002) as well as rarer mechanical ventilation (6.5% vs. 18.9%; OR = 0.36; 95% CI: 0.16-0.80; I2 = 0.48; p = 0.01).

CONCLUSIONS

Vitamin D supplementation in SARS-CoV-2 positive patients has the potential to positively impact patients with both mild and severe symptoms. As several high-quality randomized control studies have demonstrated a benefit in hospital mortality, vitamin D should be considered a supplemental therapy of strong interest. Should vitamin D prove to reduce hospitalization rates and symptoms outside of the hospital setting, the cost and benefit to global pandemic mitigation efforts would be substantial.

Increased symmetric dimethyl-arginine is a predictor factor of decreased platelet reactivity and increased bleeding risk in patients with acute coronary syndrome

Background

One of the promising biomarkers in CVD are asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA), which are products of L-arginine methylation and are both involved in endothelial dysfunction. ADMA, SDMA and L-homoarginine, have emerged as biomarkers linked to cardiovascular outcomes [1].

Purpose

To investigate the association of SDMA with platelet reactivity and bleeding risk in patients with acute coronary syndrome (ACS) treated with potent P2Y12 inhibitors prasugrel and ticagrelor.

Methods

Our prospective observational study enrolled 292 patients with ACS undergoing percuteneus coronary intervention [2]. Plasma concentrations of SDMA were measured during the hospitalization for ACS. Impedance aggregometry was used. The primary study endpoint was the concentration of metabolites and platelet reactivity. The primary clinical outcome endpoint was the incidence of Thrombolysis in Myocardial Infarction (TIMI) bleeding events (major, minor and minimal). The efficacy endpoint was the composite of major adverse cardiac events (MACE: stent thrombosis, myocardial infarction, stroke and cardiac death).

Results

There was an inverse correlation between SDMA serum levels and platelet reactivity (r=−0.25; p&lt;0.000). The ADP+PGE1-induced platelet reactivity was 33% lower among patients with the highest SDMA quartile (4th) as compared to those with the 1–3rd SDMA quartile (8 [0–29] vs 12 [0–126] U; p&lt;0.001). The AA-induced platelet reactivity was 56% lower among patients with the highest SDMA quartile (4th) as compared to those with the 1–3rd SDMA quartile (4 [0–48] vs 9 [0–133]; p&lt;0.001). In a multivariate model, the highest SDMA (4th) quartile was found to be an independent predictor of the lowest ADP+PGE1 and AA induced platelet aggregation (OR: 2.666, 95% CI [1.184–5.999], p=0.018).

Conclusions

Our study shows that high plasma concentration of SDMA, but not ADMA, is independently associated with low platelet reactivity to ADP and AA and is associated with major and minor bleeding events in patients with ACS on potent antiplatelet therapies. Therefore, SDMA might have a potential to be further evaluated as a blood biomarker for individualization of duration and potency of antiplatelet therapies in an ACS population at high risk of bleeding complications.

Acknowledgment

I-COMET research team

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

MicroRNAs as disease specific diagnostic biomarkers for neoplastic aetiology-related and inflammatory-related pericardial fluid effusion

Background and aim

Malignant involvement of the pericardium is seen in 1 to 20 percent of autopsies in patients with cancer. The most common metastatic tumor involving the pericardium is lung cancer [1]. We aimed to distinguish the origin of the pericardial fluid effusion (i.e. pericarditis vs cancer) based on miRNAs expression in peripheral blood plasma.

Method

8 patients hospitalized for collection of pericardial fluid with pericardial effusion of neoplastic aetiology (lung cancer). Control group includes 8 patients with effusion of inflammatory aetiology. Plasma RNA was extracted by mirVANAPARISKit and quality of RNA was assessed by fluorometric assay. GEP analysis was performed using the Clariom D pico chips, analysed on the Affymetrix platform. Statistical analysis by TAC software. Additional analyses were performed in and R using Signal information obtained from the TAC output. We performed the following tests using log2 transformed data and all comparison groups (A-F). Additional FDR correction, logistic regression, Mann-whitney t-test was used depending of the variables. We calculated Area under the curve using ROCp R package. Scores were ranging from 0 to 1. Co-expression analysis to identify genes authentically expressed was performed using Spearman correlation (cutoff = 0.9, Rpval = 0.05). In order to identify the targets of DE miRNAs we used our wizbionet R package and previously developed pipelines [2,3]. We performed target screening using multimiR package, selecting top 20% predictions from all available databases.

Results

We analyzed targets for all mature versions, and if DE miR was identified as pre-miR we generated -3p and -5p version for it. We also screened DisgeNet database for genes associated with cancer and pericarditis, we identified 2823 and 157 such genes. After identification of the targets of DE miRNAs we performed data aggregation, summarization and obtained information how many targets overall and targets associated with IS are regulated by each DE miRNA. Additionally we identified top targets regulated by the top miRNAs. MiR-5695, miR-4446-5p, miR-572, miR-3131 and miR-4784 were found the most significantly differentially expressed miRNAs in blood plasma for patients with malignancy compared to pericarditis. MiR-22-3p, miR-642a, miR-6771, miR-140-3p, and miR660-5p were found the most significantly differentially expressed miRNAs in pericardial fluid plasma for patients with malignancy compared to pericarditis. Importantly, miR-500b, miR-5188, miR-490, miR-24-3p, miR-383-3p were found the most promising differentially diagnostic biomarkers for malignancy and inflammatory-related pericardial fluid effusion.

Conclusions

For the first time our results indicate the differentially diagnostic power of miRNAs based on comparison of circulating in peripheral blood and pericardial fluid in patients having excessive pericardial fluid effusion due to different etiologies.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Increased Let-7e expression is associated with long-term all-cause mortality and antiplatelet treatment in patients with type 2 diabetes mellitus

Background

In the light of growing prevalence of type 2 diabetes mellitus (T2DM), efforts are made to discover novel biomarkers. MicroRNAs (miRNAs-miR) are non-coding RNAs used in various processes involved in regulating gene expression which play a role in platelet function.

Purpose

To analyze the ability of platelet-derived miRNAs in prediction of mortality and response to antiplatelet treatment among T2DM-patients.

Methods

252 diabetic subjects were enrolled and were receiving either acetylsalicylic acid (ASA) 75mg (65%) or 150 mg (15%) or clopidogrel (19%). Plasma miR-126, miR-223, miR-125a-3p and Let-7e expressions were assessed by qRT-PCR and compared between the patients who survived and those who died. Median observation time was 5.9 years. Adjusted Cox-regression analysis was used for prediction of mortality. Differential miRNAs expression due to different antiplatelet treatment was analyzed.

Results

ROC curve analysis revealed increasing concentrations of miR-126, Let-7e and miR-125a-3p levels had a diagnostic ability for prediction of long-term all-cause mortality (c-index=0.75, p&lt;0.001; 0.72, p&lt;0.001; 0.72, p=0.001, respectively). Multivariate Cox regression model revealed high miR-126 and Let-7e expressions which were strong and independent predictors of all-cause long-term mortality (HR=5.08, 95% CI: 1.92–13.43; p=0.001; HR=5.94, 95% CI: 1.98–17.79; p=0.001,respectively). After including all miRNAs into one multivariate Cox regression model, only Let-7e was predictive of future occurrence of long-term all-cause death (HR=7.83, 95% CI: 1.2–51.1; p=0.032). MiR-126, Let-7e and miR-223 expressions in the clopidogrel group were significantly higher than in the ASA group (p=0.014; p=0.013; p=0.028, respectively).

Conclusions

Let-7e expression is a strong and independent predictor of long-term all-cause mortality among patients with T2DM. MiR-223, miR-126 and Let-7e present significant interactions with antiplatelet treatment and clinical outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

MicroRNA-223 might be a predictive biomarker for major adverse cardiovascular events prognosis in patients undergoing transcatheter aortic valve implantation procedure

Background

Transcatheter aortic valve implantation (TAVI) is an emerging invasive therapeutic strategy for patients with severe aortic stenosis (AS) significantly enhancing not only quality-of-life measures but also improving short-and long-term survival rates.

Purpose

For these purposes we aimed to analyze correlation between expression levels of platelet-derived microRNAs in patients with heart failure (HF) due to AS who underwent TAVI procedure and assess their association with primary major adverse cardiac events (MACE) defined by all cause mortality and secondary MACE defined as cardiovascular mortality, ischemic stroke, and non-fatal myocardial infarction.

Methods

61 patients before and after the TAVI procedure were included. PlasmaRNA was extracted by mirVANA PARIS Kit and quality of RNA was assessed by fluorometric assay. GEP analysis was performed using the Clariom D pico chips, analyzed on the Affymetrix platform. RT-PCR was performed in order to validate the miRNAs in 61 patients by using the Taqman advanced protocol. MiRNA related to platelet function/antiplatelet treatment were chosen among those with the most relevant modulation between the groups. Wilcoxon test was performed for miRNAs comparison before and after TAVI. Calculations were performed using SPSS version 22.0, p&lt;0.05 (IBM Corporation, Chicago, USA).

Results

We have found that miR-223, miR-125b and miR-125a were significantly increased in patients after the TAVI procedure. ROC analysis showed that increased miR-223 expression after the TAVI procedure might slightly have protective value against MACE outcome.

Conclusions

Our analysis showed alteration of circulating miRNAs after the TAVI procedure and miR-223 might have a predictive value for MACE prognosis in patients with HF due to AS who underwent TAVI procedure.

Acknowledgment

I-COMET research team

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Meta-analysis of chest compression-only versus conventional cardiopulmonary resuscitation by bystanders for adult with out-of-hospital cardiac arrest

BACKGROUND

According to the guidelines of cardiopulmonary resuscitation (CPR) conducted by bystanders, two methods of CPR are feasible: standard CPR (sCPR) with mouth-to-mouth ventilations and continuous chest compression-only CPR (CCC) without rescue breathing. The goal herein, was to evaluate the effect of sCPR (30:2) and CCC on resuscitation outcomes in patients with out-of-hospital cardiac arrest (OHCA) patients.

METHODS

This study was a systematic review and meta-analysis. Using standardized criteria, Pub- Med, Web of Science, Scopus, EMBASE and Cochrane Collaboration were searched for trials assessing the effect of sCPR vs. CCC on resuscitation outcomes after adult OHCA. Random-effects model meta-analysis was applied to calculate the mean deviation (MD), odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Overall, 3 randomized controlled trials and 12 non-randomized trials met the inclusion criteria. Survival to hospital discharge with sCPR was 10.2% compared to 9.3% in the CCC group (OR = 1.04; 95% CI: 0.93-1.16; p = 0.46). Survival to hospital discharge with good neurological outcome measured with the cerebral performance category (CPC 1 or 2) was 6.5% for sCPR vs. 5.8% for CCC (OR = 1.00; 95% CI: 0.84-1.20; p = 0.98). Prehospital return of spontaneous circulation (ROSC) in sCPR and CCC groups was 15.9% and 14.8%, respectively (OR = 1.13; 95% CI: 0.91-1.39; p = 0.26). Survival to hospital admission with ROSC occurred in 29.5% of the sCPR group compared to 28.4% in CCC group (OR = 1.20; 95% CI: 0.89-1.63; p = 0.24).

CONCLUSIONS

This systematic review and meta-analysis concluded that there were no significant differences in the resuscitation outcomes between the use of standard cardiopulmonary resuscitation and chest compression only.

Impact of diabetes mellitus on in-hospital mortality in adult patients with COVID-19: a systematic review and meta-analysis

BACKGROUND

The novel coronavirus disease 2019 (COVID-19) has spread worldwide since the beginning of 2020, placing the heavy burden on the health systems all over the world. The population that particularly has been affected by the pandemic is the group of patients suffering from diabetes mellitus. Having taken the public health in considerations, we have decided to perform a systematic review and meta-analysis of diabetes mellitus on in-hospital mortality in patients with COVID-19.

METHODS

A systematic literature review (MEDLINE, EMBASE, Web of Science, Scopus, Cochrane) including all published clinical trials or observational studies published till December 10, 2020, was performed using following terms "diabetes mellitus" OR "diabetes" OR "DM" AND "survival" OR "mortality" AND "SARS-CoV-2" OR "COVID-19".

RESULTS

Nineteen studies were included out of the 7327 initially identified studies. Mortality of DM patients vs non-DM patients was 21.3 versus 6.1%, respectively (OR = 2.39; 95%CI: 1.65, 3.64; P < 0.001), while severe disease in DM and non-DM group varied and amounted to 34.8% versus 22.8% (OR = 1.43; 95%CI: 0.82, 2.50; P = 0.20). In the DM group, the complications were observed far more often when compared with non-DM group, both in acute respiratory distress (31.4 vs. 17.2%; OR = 2.38; 95%CI:1.80, 3.13; P < 0.001), acute cardiac injury (22.0% vs. 12.8%; OR = 2.59; 95%CI: 1.81, 3.73; P < 0.001), and acute kidney injury (19.1 vs. 10.2%; OR = 1.97; 95%CI: 1.36, 2.85; P < 0.001).

CONCLUSIONS

Based on the findings, we shall conclude that diabetes is an independent risk factor of the severity of COVID-19 in-hospital settings; therefore, patients with diabetes shall aim to reduce the exposure to the potential infection of COVID-19.

A systematic review and meta-analysis of effect of vitamin D levels on the incidence of COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a disease primarily affecting the respiratory tract, however due to the nature of the pathogenesis it is able to affect the whole body. So far, no causative treatment has been found and the main strategy when dealing with COVID-19 relies on widespread vaccination programs and symptomatic treatment. Vitamin D due to its ability to modulate the immunological system has been proposed as a factor playing role in the organism response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Therefore, we decided to perform this meta-analysis which aimed to establish a connection between vitamin D status and COVID-19 infection.

METHODS

Study was designed as a systematic review and meta-analysis. PubMed, EMBASE, Web of Science, Cochrane Collaboration Databases and Scopus electronic databases were searched for relevant studies from database inception to May 10th, 2021. Mean differences (MDs) with their 95% confidence intervals (CI) were calculated.

RESULTS

Thirteen studies providing data for 14,485 participants met the inclusion criteria. Mean vitamin D levels in SARS-CoV-2 negative patients was 17.7 ± 6.9 ng/mL compared to SARS-CoV-2 positive patients 14.1 ± 8.2 ng/mL (MD = 3.93; 95% CI 2.84-5.02; I2 = 99%; p < 0.001).

CONCLUSIONS

Low serum vitamin D levels are statistically significantly associated with the risk of COVID-19 infection. Supplementation of vitamin D especially in the deficiency risk groups is indicated.

Should we supplement zinc in COVID-19 patients? Evidence from meta-analysis

INTRODUCTION

Preliminary retrospective reports showed that zinc supplementation may decrease mortality in COVID-19 patients, postulating the potential therapeutic efficacy of zinc in the management of the disease.

OBJECTIVES

We sought to summarize the studies published to date regarding the antiviral activity of zinc in COVID-19 patients.

PATIENTS AND METHODS

A meta-analysis was performed to compare the outcomes of hospitalized patients receiving zinc supplementation and those treated with standard care. The primary outcome was survival to hospital discharge. Secondary outcomes were in-hospital mortality and length of stay in hospital or intensive care unit (ICU).

RESULTS

Data relating to 1474 patients included in four studies were analyzed. Survival to hospital discharge was 56.8% in the zinc group, compared to 75.9% in the non-zinc group (P=0.88). In-hospital mortality was 22.3% in the zinc group, compared to 13.6% for the standard care group (P=0.16). Length of hospital stay was 7.7(3.7) days in the zinc group and 7.2(3.9) days in the standard treatment group (P<0.001). Length of ICU stay was 4.9(1.7) days in the zinc group and 5.8(1.9) days in the standard care group (P=0.009).

CONCLUSIONS

Zinc supplementation did not have any beneficial impact on the course of COVID-19 evaluated as survival to hospital discharge and in-hospital mortality. The zinc-supplemented group had longer hospital and ICU lengths of stay. There is at present no evidence-based data to support routine zinc supplementation in COVID-19 patients.

Comparison of intravascular access methods applied by nurses wearing personal protective equipment in simulated COVID-19 resuscitation: A randomized crossover simulation trial

BACKGROUND

Prehospital emergency care of children is challenging. In the era of the COVID-19 pandemic, when medical personnel should use personal protective equipment against aerosol-generating procedures, the efficiency of medical procedures may decrease. The study objective was to evaluate the effectiveness of different intravascular access methods applied by nurses wearing biosafety Level-2 suits in simulated paediatric COVID-19 resuscitation.

METHODS

A prospective, randomized, crossover, single-blinded simulation trial was performed. Nursing staff attending Advanced Cardiovascular Life Support courses accredited by the American Heart Association participated in the study. A total of 65 nurses were recruited and randomly assigned to different study groups. They received standard training on intravascular access methods employing distinct devices. The participants wore biosafety Level-2 suits and performed vascular access with the following intraosseous devices: NIO-P, EZ-IO, and Jamshidi needle; intravenous (IV) access was used as a reference method. Both the order of participants and the access methods were random. Each participant performed intravascular access with each of the four methods tested. The effectiveness of the first attempt to obtain intravascular access and the following time parameters were analysed: the time between grasping the intravascular device out of the original packing until infusion line connection. The ease of the procedure was measured with a visual analogue scale (1 - easy; 10 - difficult).

RESULTS

The first attempt success rate of intravascular access by using NIO-P and EZ-IO equalled 100% and was statistically significantly higher than that with the Jamshidi needle (80.0%; p = 0.02) and with the IV method (69.2%; p = 0.005). The time required to connect the infusion line varied and amounted to 33 ± 4 s for NIO-P compared to 37 ± 6.7 s for EZ-IO (p<0.001), 43 ± 7 s for Jamshidi (p<0.001), and 98.5 ± 10 s for IV access (p<0.001). The procedure was easiest in the case of NIO-P and EZ-IO (2 ± 1 points; p=1.0) compared with Jamshidi (5 ± 3 points; p<0.001) and IV access (7 ± 2 points; p<0.001).

CONCLUSION

The study provides evidence that nurses wearing biosafety Level-2 suits were able to obtain intraosseous access faster and more effectively as compared with IV access during simulated COVID-19 paediatric resuscitation. The most effective method of intravascular access was the NIO-P intraosseous device. Further clinical trials are necessary to confirm the results.

Characteristics and outcomes of in-hospital cardiac arrest in COVID-19. A systematic review and meta-analysis

BACKGROUND

The purpose herein, was to perform a systematic review of interventional outcome studies in patients with in-hospital cardiac arrest before and during the coronavirus disease 2019 (COVID-19) pandemic period.

METHODS

A meta-analysis was performed of publications meeting the following PICOS criteria: (1) participants, patients > 18 years of age with cardiac arrest due to any causes; (2) intervention, cardiac arrest in COVID-19 period; (3) comparison, cardiac arrest in pre-COVID-19 period; (4) outcomes, detailed information for survival; (5) study design, randomized controlled trials, quasi-randomized or observational studies comparing cardiac arrest in COVID-19 and pre-COVID-19 period for their effects in patients with cardiac arrest.

RESULTS

Survival to hospital discharge for the pre-pandemic and pandemic period was reported in 3 studies (n =1432 patients) and was similar in the pre-pandemic vs. the pandemic period, 35.6% vs. 32.1%, respectively (odds ratio [OR] 1.72; 95% confidence interval [CI] 0.81-3.65; p = 0.16; I2 = 72%). Return of spontaneous circulation was reported by all 4 studies and were also similar in the pre and during COVID-19 periods, 51.9% vs. 48.7% (OR 1.27; 95% CI 0.78-2.07; p = 0.33; I2 = 71%), respectively. Pooled analysis of cardiac arrest recurrence was also similar, 24.9% and 17.9% (OR 1.60; 95% CI 0.99-2.57; p = 0.06; I2 = 32%) in the pre and during COVID-19 cohorts. Survival with Cerebral Performance Category 1 or 2 was higher in pre vs. during pandemic groups (27.3 vs. 9.1%; OR 3.75; 95% CI 1.26-11.20; p = 0.02). Finally, overall mortality was similar in the pre vs. pandemic groups, 65.9% and 67.2%, respectively (OR 0.67; 95% CI 0.33-1.34; p = 0.25; I2 = 76%).

CONCLUSIONS

Compared to the pre-pandemic period, in hospital cardiac arrest in COVID-19 patients was numerically higher but had statistically similar outcomes.