ABSTRACT:Postictal agitation (PIA) is an adverse effect of electroconvulsive therapy (ECT) and is known to predict other side effects of ECT, but inconsistencies in the literature remain regarding PIA prognostic factors and incidence. Therefore, a systematic review and meta-analysis were conducted (1) to identify prognostic factors for PIA following ECT and (2) to elucidate the diverse incidences of PIA following ECT based on demographic and clinical characteristics. Specifically, electronic databases were searched for retrospective observational studies and randomized controlled trials (RCTs) that objectively reported PIA incidence. Additional inclusion criteria encompassed studies involving patients 18 years or older and allowed for the extraction of PIA prognostic factors. This resulted in the inclusion of 21 articles with 66,047 patients in total. A total of 35 prognostic factors were identified for PIA after ECT, consisting of 8 anesthesia-related, 19 patient-related, and 8 ECT-related prognostic factors. A meta-analysis was conducted for 7 prognostic factors. None of the prognostic factors demonstrated a significant effect on reducing or increasing PIA incidence. Mean PIA was 13.9% (18.0% adjusted) at the patient level and 12.4% (16.5% adjusted) at the session level. Overall risk of bias was generally moderate to low, except in the outcome measurement domain, where 43% of the studies had a high risk of bias. Although none of the prognostic factors in meta-analysis were significant, several other prognostic factors consistently indicated increased or decreased risk, providing direction for future research. A scarcity of (high-quality) data emphasizes the need for additional research on this topic to be conducted.

We would like to ask the investigators of the remote haemodynamic monitoring of pulmonary artery pressures in patients with chronic heart failure (MONITOR-HF) trial1 to provide additional safety data to help clinicians assess the safety of the pulmonary artery pressure haemodynamic monitoring system (CardioMEMS; Abbott, Abbott Park, IL, USA). The haemodynamic-guided management of heart failure (GUIDE-HF) trial reported serious adverse events in 282 (57%) of 497 patients in the treatment group and 268 (53%) of 503 patients in the control group.

Despite treatment advancements, HF mortality remains high, prompting interest in reducing HF-related hospitalizations through remote monitoring. These advances are necessary considering the rapidly rising prevalence and incidence of HF worldwide, presenting a burden on hospital resources. While traditional approaches have failed in predicting impending HF-related hospitalizations, remote hemodynamic monitoring can detect changes in intracardiac filling pressure weeks prior to HF-related hospitalizations which makes timely pharmacological interventions possible. To ensure successful implementation, structural integration, optimal patient selection, and efficient data management are essential. This review aims to provide an overview of the rationale, the available devices, current evidence, and the implementation of remote hemodynamic monitoring.

Aims Despite clear guideline recommendations for initiating four drug classes in all patients with heart failure (HF) with reduced ejection fraction (HFrEF) and the availability of rapid titration schemes, information on real-world implementation lags behind. Closely following the 2021 ESC HF guidelines and 2023 focused update, the TITRATE-HF study started to prospectively investigate the use, sequencing, and titration of guideline-directed medical therapy (GDMT) in HF patients, including the identification of implementation barriers. Methods and results TITRATE-HF is an ongoing long-term HF registry conducted in the Netherlands. Overall, 4288 patients from 48 hospitals were included. Among these patients, 1732 presented with de novo, 2240 with chronic, and 316 with worsening HF. The median age was 71 years (interquartile range [IQR] 63-78), 29% were female, and median ejection fraction was 35% (IQR 25-40). In total, 44% of chronic and worsening HFrEF patients were prescribed quadruple therapy. However, only 1% of HFrEF patients achieved target dose for all drug classes. In addition, quadruple therapy was more often prescribed to patients treated in a dedicated HF outpatient clinic as compared to a general cardiology outpatient clinic. In each GDMT drug class, 19% to 36% of non-use in HFrEF patients was related to side-effects, intolerances, or contraindications. In the de novo HF cohort, 49% of patients already used one or more GDMT drug classes for other indications than HF. Conclusion This first analysis of the TITRATE-HF study reports relatively high use of GDMT in a contemporary HF cohort, while still showing room for improvement regarding quadruple therapy. Importantly, the use and dose of GDMT were suboptimal, with the reasons often remaining unclear. This underscores the urgency for further optimization of GDMT and implementation strategies within HF management. [GRAPHICS]

AimsHeart failure (HF), a global pandemic affecting millions of individuals, calls for adequate predictive guidance for improved therapy. Congestion, a key factor in HF-related hospitalizations, further underscores the need for timely interventions. Proactive monitoring of intracardiac pressures, guided by pulmonary artery (PA) pressure, offers opportunities for efficient early-stage intervention, since haemodynamic congestion precedes clinical symptoms.MethodsThe BioMEMS study, a substudy of the MONITOR-HF trial, proposes a multifaceted approach integrating blood biobank data with traditional and novel HF parameters. Two additional blood samples from 340 active participants in the MONITOR-HF trial were collected at baseline, 3-, 6-, and 12-month visits and stored for the BioMEMS biobank. The main aims are to identify the relationship between temporal biomarker patterns and PA pressures derived from the CardioMEMS-HF system, and to identify the biomarker profile(s) associated with the risk of HF events and cardiovascular death.ConclusionSince the prognostic value of single baseline measurements of biomarkers like N-terminal pro-B-type natriuretic peptide is limited, with the BioMEMS study we advocate a dynamic, serial approach to better capture HF progression. We will substantiate this by relating repeated biomarker measurements to PA pressures. This design rationale presents a comprehensive review on cardiac biomarkers in HF, and aims to contribute valuable insights into personalized HF therapy and patient risk assessment, advancing our ability to address the evolving nature of HF effectively. Design and rationale of the BioMEMS study. QoL, quality of life. Graphical abstract is created with BioRender.com image

Background and Aims In patients with chronic heart failure (HF), the MONITOR-HF trial demonstrated the efficacy of pulmonary artery (PA)-guided HF therapy over standard of care in improving quality of life and reducing HF hospitalizations and mean PA pressure. This study aimed to evaluate the consistency of these benefits in relation to clinically relevant subgroups.Methods The effect of PA-guided HF therapy was evaluated in the MONITOR-HF trial among predefined subgroups based on age, sex, atrial fibrillation, diabetes mellitus, left ventricular ejection fraction, HF aetiology, cardiac resynchronization therapy, and implantable cardioverter defibrillator. Outcome measures were based upon significance in the main trial and included quality of life-, clinical-, and PA pressure endpoints, and were assessed for each subgroup. Differential effects in relation to the subgroups were assessed with interaction terms. Both unadjusted and multiple testing adjusted interaction terms were presented.Results The effects of PA monitoring on quality of life, clinical events, and PA pressure were consistent in the predefined subgroups, without any clinically relevant heterogeneity within or across all endpoint categories (all adjusted interaction P-values were non-significant). In the unadjusted analysis of the primary endpoint quality-of-life change, weak trends towards a less pronounced effect in older patients (Pinteraction = .03; adjusted Pinteraction = .33) and diabetics (Pinteraction = .01; adjusted Pinteraction = .06) were observed. However, these interaction effects did not persist after adjusting for multiple testing.Conclusions This subgroup analysis confirmed the consistent benefits of PA-guided HF therapy observed in the MONITOR-HF trial across clinically relevant subgroups, highlighting its efficacy in improving quality of life, clinical, and PA pressure endpoints in chronic HF patients. Structured Graphical Abstract The overview figure presents the P-values associated with the interaction terms on each endpoint per subgroup. Green corresponds to an overall significant effect in the main trial, and for the predefined subgroups to no statistically significant interaction term on the associated clinical endpoint. The HFH/CV death endpoint refers to a time to event analysis of the composite endpoint HFH or CV death. AF, atrial fibrillation; CV, cardiovascular; DM, diabetes mellitus; EF, ejection fraction; GDMT, guideline-directed medical therapy; ICD, implantable cardiac defibrillator; CRT, cardiac resynchronization therapy; HF, heart failure; HFH, heart failure hospitalization; PA, pulmonary artery; PAP, pulmonary artery pressure.

Aims Remote haemodynamic monitoring with an implantable pulmonary artery (PA) sensor has been shown to reduce heart failure (HF) hospitalizations and improve quality of life. Cost-effectiveness analyses studying the value of remote haemodynamic monitoring in a pean healthcare system with a contemporary standard care group are lacking. Methods and results A Markov model was developed to estimate the cost-effectiveness of PA-guided therapy compared to the standard of care based upon patient-level data of the MONITOR-HF trial performed in the Netherlands in patients with chronic HF (New York Heart Association class III and at least one previous HF hospitalization). Cost-effectiveness was measured as the incremental cost per quality-adjusted life year (QALY) gained from the Dutch societal perspective with a lifetime horizon which encompasses a wide variety of costs including costs of hospitalizations, monitoring time, telephone contacts, laboratory assessments, and drug changes in both treatment groups. In the base-case analysis, PA-guided therapy increased costs compared to standard of care by 12 121. The QALYs per patient for PA-guided therapy and standard of care was 4.07 and 3.481, respectively, reflecting a gain of 0.58 QALYs. The resulting incremental cost-effectiveness ratio was 20 753 per QALY, which is below the Dutch willingness-to-pay threshold of 50 000 per QALY gained for HF. Conclusions The current cost-effectiveness study suggests that remote haemodynamic monitoring with PA-guided therapy on top of standard care is likely to be cost-effective for patients with symptomatic moderate-to-severe HF in the Netherlands.

Abstract Aims Current heart failure (HF) guidelines recommend to prescribe four drug classes in patients with HF with reduced ejection fraction (HFrEF). A clear challenge exists to adequately implement guideline‐directed medical therapy (GDMT) regarding the sequencing of drugs and timely reaching target dose. It is largely unknown how the paradigm shift from a serial and sequential approach for drug therapy to early parallel application of the four drug classes will be executed in daily clinical practice, as well as the reason clinicians may not adhere to new guidelines. We present the design and rationale for the real‐world TITRATE‐HF study, which aims to assess sequencing strategies for GDMT initiation, dose titration patterns (order and speed), intolerance for GDMT, barriers for implementation, and long‐term outcomes in patients with de novo, chronic, and worsening HF. Methods and results A total of 4000 patients with HFrEF, HF with mildly reduced ejection fraction, and HF with improved ejection fraction will be enrolled in >40 Dutch centres with a follow‐up of at least 3 years. Data collection will include demographics, physical examination and vital parameters, electrocardiogram, laboratory measurements, echocardiogram, medication, and quality of life. Detailed information on titration steps will be collected for the four GDMT drug classes. Information will include date, primary reason for change, and potential intolerances. The primary clinical endpoints are HF‐related hospitalizations, HF‐related urgent visits with a need for intravenous diuretics, all‐cause mortality, and cardiovascular mortality. Conclusions TITRATE‐HF is a real‐world multicentre longitudinal registry that will provide unique information on contemporary GDMT implementation, sequencing strategies (order and speed), and prognosis in de novo, worsening, and chronic HF patients.

Introduction Chronic post-surgical pain (CPSP) after lung or pleural surgery is a common complication and associated with a decrease in quality of life, long-term use of pain medication and substantial economic costs. An abundant number of primary prognostic factor studies are published each year, but findings are often inconsistent, methods heterogeneous and the methodological quality questionable. Systematic reviews and meta-analyses are therefore needed to summarise the evidence. Methods and analysis The reporting of this protocol adheres to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist. We will include retrospective and prospective studies with a follow-up of at least 3 months reporting patient-related factors and surgery-related factors for any adult population. Randomised controlled trials will be included if they report on prognostic factors for CPSP after lung or pleural surgery. We will exclude case series, case reports, literature reviews, studies that do not report results for lung or pleural surgery separately and studies that modified the treatment or prognostic factor based on pain during the observation period. MEDLINE, Scopus, Web of Science, Embase, Cochrane, CINAHL, Google Scholar and relevant literature reviews will be searched. Independent pairs of two reviewers will assess studies in two stages based on the PICOTS criteria. We will use the Quality in Prognostic Studies tool for the quality assessment and the CHARMS-PF checklist for the data extraction of the included studies. The analyses will all be conducted separately for each identified prognostic factor. We will analyse adjusted and unadjusted estimated measures separately. When possible, evidence will be summarised with a meta-analysis and otherwise narratively. We will quantify heterogeneity by calculating the Q and I-2 statistics. The heterogeneity will be further explored with meta-regression and subgroup analyses based on clinical knowledge. The quality of the evidence obtained will be evaluated according to the Grades of Recommendation Assessment, Development and Evaluation guideline 28. Ethics and dissemination Ethical approval will not be necessary, as all data are already in the public domain. Results will be published in a peer-reviewed scientific journal. PROSPERO registration number CRD42021227888.

Abstract Aims Hyperkalaemia is observed frequently in heart failure (HF) patients and is associated with an impaired prognosis and underuse of mineralocorticoid receptor antagonists (MRAs). However, the effects of serum potassium on prescription of the full guideline recommended daily dose of 50 mg in real‐world daily practice are unknown. Therefore, we investigated serum potassium and its association with the prescribed MRA dose in a large cohort of chronic HF patients. Methods and results A total of 5346 patients with chronic HF with a left ventricular ejection fraction ≤40% from 34 Dutch outpatient HF clinics between 2013 and 2016 were analysed on serum potassium and MRA (spironolactone and eplenerone) dose. Data were stratified by potassium as a serum potassium level <4.0, 4.0 to 5.0 or >5.0 mmol/L. Multivariable logistic regression models were used to assess the association between serum potassium and MRA dose and to adjust for potential confounders. Mean serum potassium was 4.4 ± 0.5 mmol/L and hyperkalaemia (serum potassium >5.0 mmol/L) was present in 399 patients (7.5%). MRA was used in 3091 patients (58.1%). Patients with hyperkalaemia significantly less often received ≥100% of the target dose (50 mg) compared with patients with a serum potassium between 4.0–5.0 mmol/L and <4.0 mmol/L (7.7% vs. 9.5% vs. 13.6% respectively, P = 0.0078). In the multivariable regression analyses, patients with hyperkalaemia were significantly less likely to receive ≥100% of the target dose compared with patients with serum potassium 4.0–5.0 mmol/L (OR 0.38, 95% CI 0.15–0.97, P = 0.044). Additionally, a one unit increase in serum potassium was significantly associated with a lower odds of receiving ≥100% of the target dose (OR 0.69, 95% CI 0.49–0.98, P = 0.036). Conclusions In this large registry of real‐world chronic HF patients, both an increase in serum potassium and hyperkalaemia were associated with a lower odds of receiving the guideline‐recommended MRA dose.

Aims: Implementation of guideline-recommended pharmacological treatment in heart failure (HF) patients remains challenging. In 2021, the European Heart Failure Association (HFA) published a consensus document in which patient profiles were created based on readily available patient characteristics and suggested that treatment adjusted to patient profile may result in better individualized treatment and improved guideline adherence. This study aimed to assess the distribution of these patient profiles and their treatment in a large real-world chronic HF cohort. Methods and results: The HFA combined categories of heart rate, blood pressure, presence of atrial fibrillation, chronic kidney disease, and hyperkalemia into eleven phenotypic patient profiles. A total of 4,455 patients with chronic HF and a left ventricular ejection fraction ≤40% with complete information on all characteristics were distributed over these profiles. In total, 1,640 patients (36.8%) could be classified into one of the HFA profiles. Three of these each comprised >5% of the population and consisted of patients with a heart rate >60 beats per minute with normal blood pressure (>90/60 mmHg) and no hyperkalemia. Conclusion: Nearly forty percent of a real-world chronic HF population could be distributed over the eleven patient profiles as suggested by the HFA. Phenotype-specific treatment recommendations are clinically relevant and important to further improve guideline implementation.

Chronic heart failure (HF) is associated with high hospital admission rates and has an enormous burden on hospital resources worldwide. Ideally, detection of worsening HF in an early phase would allow physicians to intervene timely and proactively in order to prevent HF-related hospitalizations, a concept better known as remote hemodynamic monitoring. After years of research, remote monitoring of pulmonary artery pressures (PAP) has emerged as the most successful technique for ambulatory hemodynamic monitoring in HF patients to date. Currently, the CardioMEMS and Cordella HF systems have been tested for pulmonary artery pressure monitoring and the body of evidence has been growing rapidly over the past years. However, several ongoing studies are aiming to fill the gap in evidence that is still very clinically relevant, especially for the European setting. In this comprehensive review, we provide an overview of all available evidence for PAP monitoring as well as a detailed discussion of currently ongoing studies and future perspectives for this promising technique that is likely to impact HF care worldwide.

INTRODUCTION:Chronic heart failure (HF) is characterized by high hospital admission rates. The CardioMEMSTM HF System is a pulmonary artery pressure sensor developed for remote hemodynamic monitoring to reduce HF hospitalizations. The device is FDA approved and CE marked, but clinical evidence for the CardioMEMS system is mainly based upon U.S. studies. Because of structural differences in HF care between the U.S. and Europe, it is important to study CardioMEMS efficacy in European setting on top of usual HF care and contemporary therapy. Several observational studies have been performed in Europe, but there is an unmet need for randomized clinical trials.AREAS COVERED:This review focuses on safety and efficacy data for CardioMEMS remote hemodynamic monitoring in European HF setting, and discusses important upcoming studies.EXPERT OPINION:For safety, data from European studies are in line with U.S. studies. Efficacy with regard to reduction of HF hospitalizations seems promising, but is merely based upon observational studies comparing pre- and post-implantation event rates. The first European randomized clinical trial (MONITOR HF) will provide efficacy data compared to actual standard care in a high-quality healthcare system with contemporary HF treatment and will provide important generalizable information to other European countries.

Summary Pain intensity assessment scales are important in evaluating postoperative pain and guiding management. Different scales can be used for patients to self‐report their pain, but research determining cut points between mild, moderate and severe pain has been limited to studies with < 1500 patients. We examined 13,017 simultaneous acute postoperative pain ratings from 913 patients taken at rest and on activity, between 4 h and 48 h following surgery using both a verbal rating scale (no, mild, moderate or severe pain) and 0–100 mm visual analogue scale. We determined the best cut points on the visual analogue scale between mild and moderate pain as 35 mm, and moderate and severe pain as 80 mm. These remained consistent for pain at rest and on activity, and over time. We also explored the presence of category disagreements, defined as patients verbally describing no or mild pain scored above the mild/moderate cut point on the visual analogue scale, and patients verbally describing moderate or severe pain scored below the mild/moderate cut point on the visual analogue scale. Using 30 and 60 mm cut points, 1533 observations (12%) showed a category disagreement and using 35 and 80 mm cut points, 1632 (13%) showed a category disagreement. Around 1 in 8 simultaneous pain scores implausibly disagreed, possibly resulting in incorrect pain reporting. The reasons are not known but low rates of literacy and numeracy may be contributing factors. Understanding these disagreements between pain scales is important for pain research and medical practice.

Abstract Aims Adjustment of treatment based on remote monitoring of pulmonary artery (PA) pressure may reduce the risk of hospital admission for heart failure (HF). We have conducted a meta-analysis of large randomized trials investigating this question. Methods and results A systematic literature search was performed for randomized clinical trials with PA pressure monitoring devices in patients with HF. The primary outcome of interest was the total number of HF hospitalizations. Other outcomes assessed were urgent visits leading to treatment with intravenous diuretics, all-cause mortality, and composites. Treatment effects are expressed as hazard ratios, and pooled effect estimates were obtained applying random effects meta-analyses. Three eligible randomized clinical trials were identified that included 1898 outpatients in New York Heart Association functional classes II–IV, either hospitalized for HF in the prior 12 months or with elevated plasma NT-proBNP concentrations. The mean follow-up was 14.7 months, 67.8% of the patients were men, and 65.8% had an ejection fraction ≤40%. Compared to patients in the control group, the hazard ratio (95% confidence interval) for total HF hospitalizations in those randomized to PA pressure monitoring was 0.70 (0.58–0.86) (P = .0005). The corresponding hazard ratio for the composite of total HF hospitalizations, urgent visits and all-cause mortality was 0.75 (0.61–0.91; P = .0037) and for all-cause mortality 0.92 (0.73–1.16). Subgroup analyses, including ejection fraction phenotype, revealed no evidence of heterogeneity in the treatment effect. Conclusion The use of remote PA pressure monitoring to guide treatment of patients with HF reduces episodes of worsening HF and subsequent hospitalizations.

Multiple landmark trials have helped to advance the treatment of heart failure with reduced ejection fraction (HFrEF) significantly over the past decade. These trials have led to the introduction of four main drug classes into the 2021 ESC guideline, namely angiotensin-receptor neprilysin inhibitors/angiotensin-converting-enzyme inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. The life-saving effect of these therapies has been shown to be additive and becomes apparent within weeks, which is why maximally tolerated or target doses of all drug classes should be strived for as quickly as possible. Recent evidence, such as the STRONG-HF trial, demonstrated that rapid drug implementation and up-titration is superior to the traditional and more gradual step-by-step approach where valuable time is lost to up-titration. Accordingly, multiple rapid drug implementation and sequencing strategies have been proposed to significantly reduce the time needed for the titration process. Such strategies are urgently needed since previous large-scale registries have shown that guideline-directed medical therapy (GDMT) implementation is a challenge. This challenge is reflected by generally low adherence rates, which can be attributed to factors considering the patient, health care system, and local hospital/health care provider. This review of the four medication classes used to treat HFrEF seeks to present a thorough overview of the data supporting current GDMT, discuss the obstacles to GDMT implementation and up-titration, and identify multiple sequencing strategies that could improve GDMT adherence. Graphical Abstract Sequencing strategies for GDMT implementation. GDMT: guideline-directed medical therapy; ACEi: angiotensin-converting enzyme inhibitor; ARB: Angiotensin II receptor blocker; ARNi: angiotensin receptor–neprilysin inhibitor; BB: beta-blocker; MRA: mineralocorticoid receptor antagonist; SGLT2i: sodium–glucose co-transporter 2 inhibitor

Our article provides guidance on how to interpret a meta-analysis and introduces the reader to the basics of the underlying statistical analysis. The multiple steps of a meta-analysis including systematic literature search, risk of bias assessment, data extraction and data aggregation are addressed. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach allows to score the quality of the evidence of the results revealed by a meta-analysis. Trial sequential analysis has been suggested in recent years as a method to assess the power of a meta-analysis and the risks of false positive or false negative conclusions. We also provide information on other more complex meta-analytical approaches including network meta-analysis for the comparison of several treatments as well as recent developments such as individual patient data meta-analysis and living meta-analysis.

AnaesthesiaVolume 78, Issue 3 p. 381-384 Reviewer Recommendations How to perform and write a trial sequential analysis P. R. D. Clephas, P. R. D. Clephas PhD Student orcid.org/0000-0001-9752-6962 Department of Cardiology, Erasmus University Medical Center, Rotterdam, the NetherlandsSearch for more papers by this authorP. Kranke, P. Kranke Professor Department of Anaesthesia, Critical Care, Emergency and Pain Medicine, University Hospital of Wuerzburg, Wuerzburg, GermanySearch for more papers by this authorM. Heesen, Corresponding Author M. Heesen Professor michael.heesen@ksb.ch Department of Anaesthesia and Pain Medicine, Kantonsspital Baden, Baden, Switzerland Correspondence to:M. Heesen Email: michael.heesen@ksb.chSearch for more papers by this author P. R. D. Clephas, P. R. D. Clephas PhD Student orcid.org/0000-0001-9752-6962 Department of Cardiology, Erasmus University Medical Center, Rotterdam, the NetherlandsSearch for more papers by this authorP. Kranke, P. Kranke Professor Department of Anaesthesia, Critical Care, Emergency and Pain Medicine, University Hospital of Wuerzburg, Wuerzburg, GermanySearch for more papers by this authorM. Heesen, Corresponding Author M. Heesen Professor michael.heesen@ksb.ch Department of Anaesthesia and Pain Medicine, Kantonsspital Baden, Baden, Switzerland Correspondence to:M. Heesen Email: michael.heesen@ksb.chSearch for more papers by this author First published: 13 July 2022 https://doi.org/10.1111/anae.15811Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume78, Issue3March 2023Pages 381-384 This article also appears in:Reviewer Recommendations Collection RelatedInformation

Background: Intravascular ultrasound (IVUS) can overcome the intrinsic limitations of coronary angiography for lesion assessment and stenting. IVUS improves outcomes of patients presenting with stable or complex coronary artery disease, but dedicated data on the impact of IVUS-guided percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) remains scarce.& nbsp;Methods: We systematically searched Embase, MEDLINE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar for studies that compared clinical outcomes for IVUS-versus angio-guided PCI in patients with AMI. The primary endpoint was all-cause mortality and the secondary endpoint major adverse cardiovascular events (MACE). Mantel-Haenszel random-effects model was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI).& nbsp;Results: Nine studies (8 observational, 1 RCT) with a total of 838.902 patients (796.953 angio-guided PCI, 41.949 IVUS-guided PCI) were included. In patients with AMI, IVUS-guided PCI was associated with a significantly lower risk of all-cause mortality (pooled RR: 0.70; 95% CI, 0.59-0.82; p < 0.01), MACE (pooled RR: 0.86; 95% CI, 0.74-0.99; p = 0.04) and target vessel revascularization (TVR) (pooled RR: 0.83; 95% CI, 0.73-0.95; p < 0.01). In the subset of patients presenting with ST-segment elevation, IVUS-guided PCI remained associated with a reduced risk for both all-cause mortality (pooled RR: 0.79; 95% CI, 0.66-0.95, p = 0.01) and MACE (pooled RR: 0.86; 95% CI, 0.74-0.99, p = 0.04).& nbsp;Conclusions: This is the first systematic review and meta-analysis comparing IVUS-versus angio-guided PCI in patients with AMI, showing a beneficial effect of IVUS-guided PCI on all-cause mortality, MACE and TVR. Results of ongoing dedicated prospective studies are needed to confirm these findings.