| BackgroundThe patients with acute coronary syndromes (ACS) often receive the use of anti-thrombotic drugs, fibrinolytic treatments, and the use of invasive strategies, which increases their risk for bleeding. Bleeding leads to their decreasing hemoglobin levels and then chronic anemia. Anemia is associated with a worse prognosis across the spectrum of ACS and it is a strong independent risk factor for adverse events and mortality in patients with ACS. In this scenario, transfusion of blood, can be used in the care of patients with acute coronary syndromes. However, transfusion is double-edged sword. On one hand, transfusion may be appropriate by elevating myocardial oxygen supply and alleviating anemia. On the other hand, transfusion may be detrimental by increasing circulatory overload, platelet aggregation, vasoconstriction thus leading to heart failure and recurrent myocardial ischemia. The current ACC/AHA and ESC guidelines do not demonstrate firm indications and timing for transfusion in patients with acute coronary syndromes. The American Association of Blood Banks (AABB) suggested that transfusion decisions be influenced by symptoms as well as hemoglobin concentration. They cannot recommend for or against a particular transfusion strategy in patients with acute coronary syndromes. Therefore we conducted this meta-analysis of all observational studies to evaluate the impact of transfusion on mortality and morbidity in patients with acute coronary syndrome. However, the effect of transfusion in patients with acute coronary syndromes is still uncertain.ObjectivesWe performed a meta-analysis of studies evaluating the association of blood transfusion with its clinical outcomes and aimed to provide a reference for the treatment in patients with acute coronary syndrome.Data SourcesElectronic databases from Pubmed, EMBASE and Cochrane Library were systematically searched before April2013. We extracted data sets and performed meta-analysis with standardized methods.Data ExtractionTwo reviewers independently extracted information regarding the first author’s last name, publication year, sample size, study period and duration of follow-up, characteristics of study population and age at baseline, myocardial infarction types, and baseline and nadir hemoglobin levels, and occurrences of all-cause mortality and other clinical endpoints. The study quality was assessed independently by two investigators according to the criteria for quality assessment of observational studies with the use of the nine-star Newcastle-Ottawa Scale.Methods and ResultsTwelve observational studies involving256,652participants were included in final our meta-analysis. Blood transfusion in patients with acute coronary syndrome is associated with increased all-cause mortality (P<0.001), myocardial infarction (P<0.001), congestive heart failure (P<0.001), major adverse cardiovascular events (P=0.002) and stroke (P<0.001). Transfusion is beneficial to reduce all-cause mortality at nadir hemoglobin of≤8.0g/dL (P=0.005). And transfusion is associated with increased all-cause mortality at nadir hemoglobin of>8.0g/dL (P<0.001). Blood transfusion in patients treated with PCI for acute coronary syndrome is associated with increased all-cause mortality rates (P<0.001).ConclusionBased on our meta-analysis, a restrictive blood transfusion at nadir Hb of≤8.0g/dL in patients with acute coronary syndrome may be beneficial to reduce all-cause mortality. Blood transfusion at nadir Hb of>8.0g/dL in patients with ACS was found to be harmful or, at best, neutral. Transfusion is associated with increased all-cause mortality rates in patients undergoing PCI for acute coronary syndrome. BackgroundChronic heart failure (CHF) is a major cause of morbidity and mortality in the general population, and healthcare expenditure on it in developed countries consumes1-2%of the total health care budget. Declining left ventricular ejection fraction (LVEF) of HF patients is an important and powerful predictor of cardiovascular outcomes, and very10%reduction in LVEF below45%was independently associated with a39%increased risk for all-cause mortality.Current evidence-based practice guidelines recommended that ARBs are a reasonable alternative in patients with heart failure with reduced ejection fraction (HFrEF) intolerant of angiotensin-converting enzyme inhibitors (ACEIs) unless contraindicated, to reduce morbidity and mortality. This is in spite of the theoretical hypothesis that ARBs could potentially better suppress the effects of the renin-angiotensin-aldosterone system. A Cochrane review indicated that ARBs were no better than placebo or ACE inhibitors in reducing the risk of death, disability, or hospital admission for any reason. Nevertheless, this systematic review did not include data neither from Maggioni et al., a subgroup analysis of the Valsartan Heart Failure Trial (Val-HeFT) nor from Cice et al. Data from the former study would suggest a favorable effect of an ARB on mortality and morbidity in patients with HF not treated with ACEIs. The latter study was published subsequent to Cochrane review. The role for angiotensin receptor blockers in the treatment of chronic heart failure with reduced ejection fraction is controversial.ObjectivesWe performed a meta-analysis to examine the effect of angiotensin receptor blockers on the treatment of chronic heart failure with reduced ejection fraction.Data SourcesElectronic databases from Pubmed, EMBASE and Cochrane Library were systematically searched before September2013. We extracted data sets and performed meta-analysis with standardized methods.Data ExtractionTwo reviewers independently extracted information regarding eligible studies, New York Heart Association Functional Class, ejection fraction, total number of participants, types of ARBs and ACEIs, mean follow-up, Jadad score and end-points. The study quality was assessed independently by two investigators according to the criteria of Jadad score for quality assessment.Methods and ResultsTwenty-three studies involving13,532patients met the inclusion criteria. ARBs reduce all-cause mortality, cardiovascular mortality, and hospitalizations for heart failure compared with placebo without background ACEIs therapy. ARBs did not differ from ACEIs in reducing all-cause mortality, cardiovascular mortality, hospitalizations for heart failure, but lowered withdrawals due to adverse effects versus ACEIs. Combination of ARBs and ACEIs reduced cardiovascular mortality, but did not reduce total mortality or hospitalizations for heart failure compared with ACEIs alone, and it increased the risk of withdrawals due to adverse effects. ConclusionThis meta-analysis suggests the superiority of ARBs over placebo in reducing mortality and morbidity in patients with heart failure with reduced ejection fraction. ARBs are better tolerated than ACEIs. Close monitoring for adverse effects may be warranted in the combination therapy of ARBs and ACEIs. Objectives The relationship between blood transfusion and its clinical outcomes in patients with acute coronary syndrome is arresting but controversial. Some publications have studied the effect of blood transfusion on patients with acute coronary syndrome, with inconsistent results. Thus we performed a meta-analysis of studies evaluating the association of blood transfusion with its clinical outcomes and aimed to provide a reference for the treatment in patients with acute coronary syndrome.Methods Electronic databases from Pubmed, EMBASE and Cochrane Library were systematically searched before April2013. We extracted data sets and performed meta-analysis with standardized methods.Results Twelve observational studies involving256,652participants were included in final our meta-analysis. Blood transfusion in patients with acute coronary syndrome is associated with increased all-cause mortality (P<0.001), myocardial infarction (P<0.001), congestive heart failure (P<0.001), major adverse cardiovascular events (P=0.002) and stroke (P<0.001). Transfusion is beneficial to reduce all-cause mortality at nadir hemoglobin of≤8.0g/dL (P=0.005). And transfusion is associated with increased all-cause mortality at nadir hemoglobin of>8.0g/dL (P<0.001). Blood transfusion in patients treated with PCI for acute coronary syndrome is associated with increased all-cause mortality rates (P<0.001). Conclusions Based on the present meta-analysis, we found that a restrictive blood transfusion at nadir Hb of≤8.0g/dL in patients with acute coronary syndrome may be beneficial to reduce all-cause mortality. Blood transfusion at nadir Hb of>8.0g/dL in patients with ACS was found to be harmful or, at best, neutral. Transfusion is associated with increased all-cause mortality rates in patients undergoing PCI for acute coronary syndrome. Objectives:We performed a meta-analysis to examine the effect of angiotensin receptor blockers on the treatment of chronic heart failure with reduced ejection fraction.Methods:A total of23clinical trials involving13,532patients were identified. We searched MEDLINE, EMBASE and Cochrane Library systematically for all relevant randomized controlled trials. Risk ratios and corresponding95%confidence intervals were applied to assess the role of angiotensin receptor blockers in chronic heart failure with reduced ejection fraction.Results:Twenty-three studies involving13,532patients met the inclusion criteria. ARBs reduce all-cause mortality, cardiovascular mortality, and hospitalizations for heart failure compared with placebo without background ACEIs therapy. ARBs did not differ from ACEIs in reducing all-cause mortality, cardiovascular mortality, hospitalizations for heart failure, but lowered withdrawals due to adverse effects versus ACEIs. Combination of ARBs and ACEIs reduced cardiovascular mortality, but did not reduce total mortality or hospitalizations for heart failure compared with ACEIs alone, and it increased the risk of withdrawals due to adverse effects.Conclusions:This meta-analysis suggests the superiority of ARBs over placebo in reducing mortality and morbidity in patients with heart failure with reduced ejection fraction. ARBs are better tolerated than ACEIs. Close monitoring for adverse effects may be warranted in the combination therapy of ARBs and ACEIs. |
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