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  • 11
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    Online Resource
    Duration of dual antiplatelet therapy and stability of coronary heart disease: a 60 000-patient meta-analysis of randomised controlled trials
    BMJ ; 2021
    In:  Open Heart Vol. 8, No. 2 ( 2021-07), p. e001707-
    Details
    In: Open Heart, BMJ, Vol. 8, No. 2 ( 2021-07), p. e001707-
    Abstract: Dual antiplatelet therapy (DAPT) has important implications for clinical outcomes in coronary disease. However, the optimal DAPT duration remains uncertain. Methods and results We searched four major databases for randomised controlled trials comparing long-term (≥12 months) with short-term (≤6 months) or shorter (≤3 months) DAPT in patients with coronary syndromes. The primary outcome was all-cause mortality. Secondary outcomes were any bleeding and major bleeding (safety), cardiac death, myocardial infarction, stent thrombosis, revascularisation and stroke (efficacy). Nineteen randomised controlled trials (n=60 111) satisfied inclusion criteria, 8 assessed ≤3 months DAPT. Compared with long-term (≥12 months), short-term DAPT (≤6 months) was associated with a trend towards reduced all-cause mortality (RR: 0.90, 95% CI: 0.80 to 1.01) and significant bleeding reduction (RR: 0.68, 95% CI: 0.55 to 0.83 and RR: 0.66, 95% CI: 0.56 to 0.77 for major and any bleeding, respectively). There were no significant differences in efficacy outcomes. These associations persisted in sensitivity analysis comparing shorter duration DAPT (≤3 months) to long-term DAPT (≥12 months) for all-cause mortality (RR: 0.91, 95% CI: 0.79 to 1.05). In subgroup analysis, short-term DAPT was associated with lower risk of bleeding in patients with acute or chronic coronary syndromes (RR: 0.66, 95% CI: 0.54 to 0.81 and RR: 0.53, 95% CI: 0.33 to 0.65, respectively), but higher risk of stent thrombosis in acute coronary syndrome (RR: 1.49, 95% CI: 1.02 to 2.17 vs RR: 1.25, 95% CI 0.44 to 3.58). Conclusion Our meta-analysis suggests that short (≤6 months) and shorter (≤3 months) durations DAPT are associated with lower risk of bleeding, equivalent efficacy and a trend towards lower all-cause mortality irrespective of coronary artery disease stability.
    Type of Medium: Online Resource
    ISSN: 2053-3624
    URL: Article
    DOI: 10.1136/openhrt-2021-001707
    Language: English
    Publisher: BMJ
    Publication Date: 2021
    detail.hit.zdb_id: 2747269-3
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  • 12
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    Adverse health effects associated with household air pollution: a systematic review, meta-analysis, and burden estimation study
    Elsevier BV ; 2020
    In:  The Lancet Global Health Vol. 8, No. 11 ( 2020-11), p. e1427-e1434
    Details
    In: The Lancet Global Health, Elsevier BV, Vol. 8, No. 11 ( 2020-11), p. e1427-e1434
    Type of Medium: Online Resource
    ISSN: 2214-109X
    URL: Article
    DOI: 10.1016/S2214-109X(20)30343-0
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2020
    detail.hit.zdb_id: 2723488-5
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  • 13
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    Data science in undergraduate medicine: Course overview and student perspectives
    Elsevier BV ; 2022
    In:  International Journal of Medical Informatics Vol. 159 ( 2022-03), p. 104668-
    Details
    In: International Journal of Medical Informatics, Elsevier BV, Vol. 159 ( 2022-03), p. 104668-
    Type of Medium: Online Resource
    ISSN: 1386-5056
    URL: Article
    DOI: 10.1016/j.ijmedinf.2021.104668
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2022
    detail.hit.zdb_id: 1466296-6
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  • 14
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    Personalized diagnosis in suspected myocardial infarction
    Springer Science and Business Media LLC ; 2023
    In:  Clinical Research in Cardiology Vol. 112, No. 9 ( 2023-09), p. 1288-1301
    Details
    In: Clinical Research in Cardiology, Springer Science and Business Media LLC, Vol. 112, No. 9 ( 2023-09), p. 1288-1301
    Abstract: In suspected myocardial infarction (MI), guidelines recommend using high-sensitivity cardiac troponin (hs-cTn)-based approaches. These require fixed assay-specific thresholds and timepoints, without directly integrating clinical information. Using machine-learning techniques including hs-cTn and clinical routine variables, we aimed to build a digital tool to directly estimate the individual probability of MI, allowing for numerous hs-cTn assays. Methods In 2,575 patients presenting to the emergency department with suspected MI, two ensembles of machine-learning models using single or serial concentrations of six different hs-cTn assays were derived to estimate the individual MI probability (ARTEMIS model). Discriminative performance of the models was assessed using area under the receiver operating characteristic curve (AUC) and logLoss. Model performance was validated in an external cohort with 1688 patients and tested for global generalizability in 13 international cohorts with 23,411 patients. Results Eleven routinely available variables including age, sex, cardiovascular risk factors, electrocardiography, and hs-cTn were included in the ARTEMIS models. In the validation and generalization cohorts, excellent discriminative performance was confirmed, superior to hs-cTn only. For the serial hs-cTn measurement model, AUC ranged from 0.92 to 0.98. Good calibration was observed. Using a single hs-cTn measurement, the ARTEMIS model allowed direct rule-out of MI with very high and similar safety but up to tripled efficiency compared to the guideline-recommended strategy. Conclusion We developed and validated diagnostic models to accurately estimate the individual probability of MI, which allow for variable hs-cTn use and flexible timing of resampling. Their digital application may provide rapid, safe and efficient personalized patient care. Trial Registration numbers Data of following cohorts were used for this project: BACC ( www.clinicaltrials.gov ; NCT02355457), stenoCardia ( www.clinicaltrials.gov ; NCT03227159), ADAPT-BSN ( www.australianclinicaltrials.gov.au ; ACTRN12611001069943), IMPACT ( www.australianclinicaltrials.gov.au , ACTRN12611000206921), ADAPT-RCT ( www.anzctr.org.au ; ANZCTR12610000766011), EDACS-RCT ( www.anzctr.org.au ; ANZCTR12613000745741); DROP-ACS ( https://www.umin.ac.jp , UMIN000030668); High-STEACS ( www.clinicaltrials.gov ; NCT01852123), LUND ( www.clinicaltrials.gov ; NCT05484544), RAPID-CPU ( www.clinicaltrials.gov ; NCT03111862), ROMI ( www.clinicaltrials.gov ; NCT01994577), SAMIE ( https://anzctr.org.au ; ACTRN12621000053820), SEIGE and SAFETY ( www.clinicaltrials.gov ; NCT04772157), STOP-CP ( www.clinicaltrials.gov ; NCT02984436), UTROPIA ( www.clinicaltrials.gov ; NCT02060760). Graphical Abstract
    Type of Medium: Online Resource
    ISSN: 1861-0684 , 1861-0692
    URL: Article
    DOI: 10.1007/s00392-023-02206-3
    RVK:
    XA 37040
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2023
    detail.hit.zdb_id: 2218331-0
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  • 15
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    Improving Risk Stratification for Patients With Type 2 Myocardial Infarction
    Elsevier BV ; 2023
    In:  Journal of the American College of Cardiology Vol. 81, No. 2 ( 2023-01), p. 156-168
    Details
    In: Journal of the American College of Cardiology, Elsevier BV, Vol. 81, No. 2 ( 2023-01), p. 156-168
    Type of Medium: Online Resource
    ISSN: 0735-1097
    URL: Article
    DOI: 10.1016/j.jacc.2022.10.025
    RVK:
    XA 17760
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2023
    detail.hit.zdb_id: 1468327-1
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  • 16
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    APPLICATION OF THE UNIVERSAL DEFINITION OF MYOCARDIAL INFARCTION IN PRACTICE
    Elsevier BV ; 2023
    In:  Journal of the American College of Cardiology Vol. 81, No. 8 ( 2023-03), p. 1292-
    Details
    In: Journal of the American College of Cardiology, Elsevier BV, Vol. 81, No. 8 ( 2023-03), p. 1292-
    Type of Medium: Online Resource
    ISSN: 0735-1097
    URL: Article
    DOI: 10.1016/S0735-1097(23)01736-9
    RVK:
    XA 17760
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2023
    detail.hit.zdb_id: 1468327-1
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  • 17
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    Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Circulation Vol. 144, No. 7 ( 2021-08-17), p. 528-538
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 144, No. 7 ( 2021-08-17), p. 528-538
    Abstract: Although the 99th percentile is the recommended diagnostic threshold for myocardial infarction, some guidelines also advocate the use of higher troponin thresholds to rule in myocardial infarction at presentation. It is unclear whether the magnitude or change in troponin concentration can differentiate causes of myocardial injury and infarction in practice. Methods: In a secondary analysis of a multicenter randomized controlled trial, we identified 46 092 consecutive patients presenting with suspected acute coronary syndrome without ST-segment–elevation myocardial infarction. High-sensitivity cardiac troponin I concentrations at presentation and on serial testing were compared between patients with myocardial injury and infarction. The positive predictive value and specificity were determined at the sex-specific 99th percentile upper reference limit and rule-in thresholds of 64 ng/L and 5-fold of the upper reference limit for a diagnosis of type 1 myocardial infarction. Results: Troponin was above the 99th percentile in 8188 patients (18%). The diagnosis was type 1 or type 2 myocardial infarction in 50% and 14% and acute or chronic myocardial injury in 20% and 16%, respectively. Troponin concentrations were similar at presentation in type 1 (median [25th–75th percentile] 91 [30–493] ng/L) and type 2 (50 [22–147] ng/L) myocardial infarction and in acute (50 [26–134] ng/L) and chronic (51 [31–130] ng/L) myocardial injury. The 99th percentile and rule-in thresholds of 64 ng/L and 5-fold upper reference limit gave a positive predictive value of 57% (95% CI, 56%–58%), 59% (58%–61%), and 62% (60%–64%) and a specificity of 96% (96%–96%), 96% (96%–96%), and 98% (97%–98%), respectively. The absolute, relative, and rate of change in troponin concentration were highest in patients with type 1 myocardial infarction ( P 〈 0.001 for all). Discrimination improved when troponin concentration and change in troponin were combined compared with troponin concentration at presentation alone (area under the curve, 0.661 [0.642–0.680] versus 0.613 [0.594–0.633] ). Conclusions: Although we observed important differences in the kinetics, cardiac troponin concentrations at presentation are insufficient to distinguish type 1 myocardial infarction from other causes of myocardial injury or infarction in practice and should not guide management decisions in isolation. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01852123.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/CIRCULATIONAHA.121.054302
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 18
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    High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction: A Stepped-Wedge Cluster Randomized Controlled Trial
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Circulation Vol. 143, No. 23 ( 2021-06-08), p. 2214-2224
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 143, No. 23 ( 2021-06-08), p. 2214-2224
    Abstract: High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the safety and efficacy of this approach is uncertain. We investigated whether an early rule-out pathway is safe and effective for patients with suspected acute coronary syndrome. Methods: We performed a stepped-wedge cluster randomized controlled trial in the emergency departments of 7 acute care hospitals in Scotland. Consecutive patients presenting with suspected acute coronary syndrome between December 2014 and December 2016 were included. Sites were randomized to implement an early rule-out pathway where myocardial infarction was excluded if high-sensitivity cardiac troponin I concentrations were 〈 5 ng/L at presentation. During a previous validation phase, myocardial infarction was ruled out when troponin concentrations were 〈 99th percentile at 6 to 12 hours after symptom onset. The coprimary outcome was length of stay (efficacy) and myocardial infarction or cardiac death after discharge at 30 days (safety). Patients were followed for 1 year to evaluate safety and other secondary outcomes. Results: We enrolled 31 492 patients (59±17 years of age [mean±SD]; 45% women) with troponin concentrations 〈 99th percentile at presentation. Length of stay was reduced from 10.1±4.1 to 6.8±3.9 hours (adjusted geometric mean ratio, 0.78 [95% CI, 0.73–0.83]; P 〈 0.001) after implementation and the proportion of patients discharged increased from 50% to 71% (adjusted odds ratio, 1.59 [95% CI, 1.45–1.75]). Noninferiority was not demonstrated for the 30-day safety outcome (upper limit of 1-sided 95% CI for adjusted risk difference, 0.70% [noninferiority margin 0.50%] ; P =0.068), but the observed differences favored the early rule-out pathway (0.4% [57/14 700] versus 0.3% [56/16 792] ). At 1 year, the safety outcome occurred in 2.7% (396/14 700) and 1.8% (307/16 792) of patients before and after implementation (adjusted odds ratio, 1.02 [95% CI, 0.74–1.40]; P =0.894), and there were no differences in hospital reattendance or all-cause mortality. Conclusions: Implementation of an early rule-out pathway for myocardial infarction reduced length of stay and hospital admission. Although noninferiority for the safety outcome was not demonstrated at 30 days, there was no increase in cardiac events at 1 year. Adoption of this pathway would have major benefits for patients and health care providers. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03005158.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/CIRCULATIONAHA.120.052380
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 19
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    Abstract 16401: Duration of Dual Antiplatelet Therapy in Coronary Heart Disease: A 60,000-patient Meta-analysis of Randomised Controlled Trials
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Circulation Vol. 142, No. Suppl_3 ( 2020-11-17)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 142, No. Suppl_3 ( 2020-11-17)
    Abstract: Introduction: Dual antiplatelet therapy (DAPT) is the cornerstone of pharmacological treatment for patients with acute coronary syndrome (ACS) and in those undergoing percutaneous coronary intervention for stable coronary disease. Despite widespread use, the optimal duration of DAPT remains uncertain. We present an updated meta-analysis comparing outcomes in short-term DAPT (≤ 6 months) versus long-term DAPT (≥ 12 months). Methods: Four major databases were searched for randomised controlled trials of interest. The primary outcome was all-cause mortality. Secondary safety outcomes included any bleeding and major bleeding. Efficacy outcomes included cardiovascular death, myocardial infarction, stent thrombosis, coronary revascularization and thrombotic stroke. Further subgroup analysis stratified by index presentation and a sensitivity analysis to evaluate shorter duration DAPT (≤3 months) was performed. Results: Nineteen randomised controlled trials were included (n=60,879) of which 8 compared shorter duration DAPT (≤3 months) with standard duration (12 months) (n=38,036). Short-term DAPT was associated with an apparent modest increase in myocardial infarction (risk ratio [RR] 1.09; 95% confidence interval [CI] , 0.98-1.22) with a major reduction in bleeding (RR 0.68; 95% CI, 0.55-0.83) for major bleeding and (RR 0.66; 95% CI, 0.56-0.77 for any bleeding) and an overall apparent reduction in all-cause mortality (RR 0.90; 95% CI 0.81-1.01). These associations persisted when comparing shorter duration DAPT to standard duration. Subgroup analysis of patients with stable disease or ACS identified no significant heterogenicity in efficacy, safety or mortality outcomes. Conclusion: In the largest meta-analysis to date comparing duration of DAPT, we show that short (≤ 6 months) and shorter (≤ 3 months) DAPT is associated with continuing trends for small reductions in all-cause mortality irrespective of index presentation.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.142.suppl_3.16401
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 20
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    Abstract 8905: Cardiac Troponin Thresholds and Kinetics to Differentiate Myocardial Injury and Myocardial Infarction
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Circulation Vol. 144, No. Suppl_1 ( 2021-11-16)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 144, No. Suppl_1 ( 2021-11-16)
    Abstract: Background: Whilst the 99th percentile is the recommended diagnostic threshold for myocardial infarction (MI), some guidelines also advocate the use of higher troponin thresholds to rule-in MI at presentation. It is unclear whether the magnitude or change in troponin concentration can differentiate causes of myocardial injury and infarction in practice. Hypothesis: Troponin concentration alone cannot to distinguish subtypes of myocardial infarction Methods: In a secondary analysis of a multi-centre randomized controlled trial, we identified 46,092 consecutive patients presenting with suspected acute coronary syndrome without STEMI. High-sensitivity troponin I concentrations at presentation and on serial testing were evaluated. The positive predictive value (PPV) and specificity were determined at the sex-specific 99th percentile upper reference limit (URL), and rule-in thresholds of 64 ng/L and 5-fold of the URL for a diagnosis of type 1 MI. Results: Troponin concentrations were similar at presentation in type 1 (median [IQR] 91 [30-493] ng/L) and type 2 MI (50 [22-147] ng/L), and in acute (50 [26-134] ng/L) and chronic (51 [31-130] ng/L) myocardial injury (Figure A). The 99th percentile and rule-in thresholds of 64 ng/L and 5-fold URL gave a PPV of 57% (95% confidence interval [CI] 56-58%), 59% (58-61%) and 62% (60-64%), and a specificity of 96% (96-96%), 96% (96-96%) and 98% (97-98%), respectively (Figure B). The absolute, relative and rate of change in troponin concentration was highest in patients with type 1 MI (P 〈 0.001 for all, Figure C). Discrimination improved when troponin concentration and change in troponin were combined compared to troponin concentration at presentation alone (area under curve, 0.661 versus 0.613). Conclusions: Troponin concentrations at presentation are insufficient to distinguish type 1 MI from other causes of myocardial injury or infarction in practice and should not guide management decisions in isolation.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.144.suppl_1.8905
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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