Elbenawi, Hossam

ABSTRACTBackgroundAnemia is frequently observed as a comorbidity in atrial fibrillation (AF), especially in elderly patients and in those on anticoagulation. This has been associated with poor clinical outcomes. We aim to investigate the impact of anemia on clinical outcomes in patients with AF on oral anticoagulation.MethodsWe comprehensively searched PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through March 2024 and conducted a prognostic systematic review and meta‐analysis. All analyses were performed using R V. 4.3.1. This meta‐analysis was registered at PROSPERO (CRD42024556023).ResultsWe included 23 studies comprising 286,781 patients for analysis. Anemia had a significant association with an 84% increase in risk of major bleeding (HR: 1.84 with 95% CI [1.59, 2.13], p < 0.01), a 32% increase in the risk of intracranial hemorrhage (HR: 1.32 with 95% CI [1.10, 1.58], p < 0.01), a 98% increase in the risk of gastrointestinal bleeding (HR: 1.98 with 95% CI [1.67, 2.35], p < 0.01), and a 91% increase in the risk of all‐cause mortality (HR: 1.91 with 95% CI [1.46, 2.51], p < 0.01). However, the impact of anemia did not significantly affect the risk of stroke, transient ischemic stroke (TIA), or systemic embolism (HR: 1.07 with 95% CI [0.93, 1.22], p = 0.36).ConclusionAnemia was significantly associated with an increased risk of major bleeding, intracranial hemorrhage, gastrointestinal bleeding, and all‐cause mortality. However, anemia did not significantly impact stroke, TIA, or systemic embolism.

Background: Naples prognostic score (NPS) is a recently developed tool for assessing inflammatory and nutritional status. It is commonly used to evaluate cancer patients. Purpose: We aimed to investigate the impact of NPS on clinical outcomes in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI). Methods: We comprehensively searched PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through June 2024. We conducted a systematic review and meta-analysis pooling dichotomous data using risk ratio (RR) with a 95% confidence interval (CI). All analyses were performed using R V. 4.3.1. Results: We included five studies with a total of 12,785 patients. Comparing high NPS (3-4) to low NPS (0-2), high NPS (3-4) was significantly associated with an increased incidence of overall mortality (RR: 2.21, 95% CI [1.85, 2.65], P < 0.01), shock (RR: 1.85, 95% CI [1.33, 2.57], P < 0.01), acute kidney injury (RR: 1.54, 95% CI [1.15, 2.08], P < 0.01), left ventricular thrombus (RR: 2.93, 95% CI [1.44, 5.94], P < 0.01), and no-reflow (RR: 1.35, 95% CI [1.17, 1.57], P < 0.01). However, there was no significant difference between high NPS (3-4) and low NPS (0-2) regarding in-hospital mortality (RR: 1.82, 95% CI [0.99, 3.37], P = 0.06). Conclusion: Our meta-analysis highlights the importance of evaluating inflammation and malnutrition status in STEMI and shows that routine blood tests can provide prognostic insights. NPS can help predict different clinical outcomes in STEMI patients undergoing PPCI. While it does not affect in-hospital mortality, its simplicity and accessibility make it useful for clinical risk assessment and long-term prognosis. Further studies are needed to investigate its predictive value further.

Background: Refractory angina severely affects patients' quality of life around the world. Among the new treatment methods, the coronary sinus reducer (CSR) is one of the most thoroughly researched. Purpose: We aim to investigate the efficacy and safety of CSR for refractory angina. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) from PubMed, Web of Science, Scopus, Embase, and Cochrane searches until May 2024. Dichotomous data were pooled using risk ratio (RR), and continuous data were pooled using mean difference (MD), both with a 95% confidence interval (CI), using (R version 4.3). Results: With the inclusion of three RCTs, our cohort comprised a total of 180 patients. Compared to the control group, after six months, CSR was significantly associated with decreased mean change of Canadian cardiovascular society (CCS) class (MD: -0.54 with 95% CI [-0.80, -0.27], P< 0.01), an increased number of patients in the CCS class I (RR: 2.29 with 95% CI [1.14, 4.61], P= 0.02), a decreased number of patients in the CCS class III (RR: 0.53 with 95% CI [0.32, 0.87], P= 0.01), and increased exercise time (MD: 50.46 with 95% CI [9.47, 91.45], P= 0.02). However, there was no significant difference between CSR and the control group in CCS class II, class IV, across all Seattle Angina Questionnaire (SAQ) domains, the incidence of any serious adverse events (RR: 3.44 with 95% CI [0.82, 14.42], P= 0.09), stroke (RR: 2.13 with 95% CI [0.20, 22.88], P= 0.53), and all-cause mortality (RR: 1.06 with 95% CI [0.07, 16.59], P= 0.97). Conclusion: CSR has been shown to reduce angina severity by lowering CCS class scores and increasing exercise time. Large-scale RCTs are needed to confirm its effectiveness in patients with refractory angina.

Introduction: Atrial fibrillation is the most encountered arrhythmia in clinical settings, with an estimate of 6 million cases in the United States. A growing amount of evidence has been supporting the role of left atrial appendage in left sided atrial fibrillation with conflict results. We aim in this study to provide a more in-depth guide for optimal left sided atrial fibrillation ablation strategy. Methods: We searched PubMed, Web of Science, Cochrane and Scopus for published studies until May 2024. We included relevant studies that compared the left atrial appendage electrical isolation versus the standard ablation and reported our outcomes of interest. The main outcomes of the study were the recurrence of atrial arrhythmia and the incidence of stroke or transient ischemic attack during the follow-up period. Data were pooled as Mean difference (MD) or risk ratio (RR) with their 95% CI using a fixed-effect model. Results: Eleven studies with 3040 patients were included in the final analysis. Left atrial appendage electrical isolation was associated with a significant reduction in atrial arrhythmia recurrence compared to the standard ablation alone (OR: 0.41, 95% CI: 0.35 to 0.48). However, it was also associated with a significant increase in stroke or transient ischemic attack incidence (OR: 1.48, 95% CI: 1.09 to 3.12). Conclusion: Left atrial appendage electrical isolation led to a significantly lower atrial arrhythmia recurrence, but this was achieved with an increased risk of stroke and transient ischemic attack incidence during the follow-up period.

Background: Air pollution is a leading cause of cardiovascular diseases including ischemic heart disease and stroke contributing to millions of deaths, with elevated blood pressure, endothelial dysfunction, and systemic inflammation being some of the most important underlying mechanisms. Various studies showed a promising beneficial effect of indoor air purification on various health outcomes, including blood pressure. We aimed to assess the effect of indoor air purification on systolic blood pressure (SBP) and Diastolic blood pressure (DBP) and provide a rationale for home use of these filters. Methods: We searched PubMed, Web of Science, Cochrane and Scopus for published literature up to May 2024. We included studies that assessed air purification, including HEPA filters or electrostatic air filters, as an intervention compared to no intervention. The primary outcome of interest was mean changes in blood pressure both systolic and diastolic. Secondary outcomes were biomarkers of inflammation and oxidative stress. Mean difference (MD) and 95% CI was used in a fixed-effect model to analyze the data. Results: A total of 21 studies were included in our meta-analysis with a total of 1955 participants. Air purification was associated with a significant reduction in systolic blood pressure (SBP) (MD: -2.42, 95% CI: -3.42, -1.41), and diastolic blood pressure (DBP) (MD: -1.11, 95% CI: -1.76, -0.46). However, there was no significant changes in levels of inflammatory biomarkers or oxidative stress. Conclusion: Indoor air purification was associated with significant reductions in systolic and diastolic blood pressure levels, but questions arise whether these reductions are clinically relevant or not. Further studies should assess these findings. Conclusion: Indoor air purification was associated with significant reductions in systolic and diastolic blood pressure levels, but questions arise whether these reductions are clinically relevant or not. Further studies should assess these findings.

Background: Current clinical guidelines emphasize the significance of rhythm control with catheter ablation but lack guidance on the timing after diagnosing atrial fibrillation (AF). Purpose: We aim to investigate the latest evidence on the impact of diagnosis to ablation time (DAT) on AF recurrence, all-cause mortality, stroke, and heart failure (HF) after AF catheter ablation. Methods: We comprehensively searched PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through February 2024. We conducted a pair-wise and prognostic systematic review and meta-analysis with a reconstructed time-to-event data meta-analysis. All analyses were performed using R V. 4.3.1. PROSPERO ID: CRD42024525542. Results: With the inclusion of 22 studies, our cohort comprised a total of 42,101 patients. Regarding pair-wise meta-analysis, shorter DAT was significantly associated with a decreased incidence of AF recurrence across paroxysmal and persistent AF subgroups. Moreover, DAT ≤ one year was significantly associated with a decreased incidence of all-cause mortality (RR: 0.73 with 95% CI [0.59, 0.92], P< 0.01) with a trend toward lowering the risk of stroke (RR: 0.80 with 95% CI [0.62, 1.03], P= 0.08). However, there was no significant difference between DAT ≤ one year and DAT > one year in HF. Regarding adjusted prognostic meta-analysis, longer DAT was significantly associated with an increased risk of AF recurrence (P < 0.01). Our reconstructed Kaplan Meier showed that DAT > one year was significantly associated with a 50% increase in the risk of AF recurrence compared to DAT ≤ one year (HR: 1.50 with 95% CI [1.42, 1.58], P< 0.00001) over 60 months follow-up. Conclusion: Our meta-analysis strongly underscores the critical importance of a short DAT in significantly reducing AF recurrence and all-cause mortality, with a trend toward lowering stroke risk, though no significant impact on HF was observed. Early ablation proves beneficial not only for patients with paroxysmal AF but also for those with persistent AF. These findings suggest that minimizing DAT can markedly improve AF outcomes, warranting further investigation to optimize treatment strategies.

Background: Heart failure (HF) is associated with systemic inflammation and hypercatabolic syndrome, impacting body metabolism. The advanced lung cancer inflammation index (ALI) is a novel inflammatory and nutritional biomarker. Purpose: We aimed to investigate the prognostic role of ALI in patients with HF. Methods: We comprehensively searched PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through March 2024. We conducted a pair-wise and prognostic systematic review and meta-analysis with a reconstructed time-to-event data meta-analysis. All analyses were performed using R V. 4.3.1. This meta-analysis was registered at PROSPERO (CRD42024535227). Results: We included four studies with 2,247 patients. In the pair-wise meta-analysis, ALI ≤ 25 was significantly associated with an increased incidence of all-cause mortality compared with ALI > 25 (risk ratio [RR] 1.73, 95% confidence interval [CI] 1.36-2.21, P< 0.01). On the adjusted prognostic meta-analysis, higher ALI (>25) was significantly associated with a reduction in the incidence of all-cause mortality (hazards ratio [HR] 0.45, 95% CI 0.35-0.58, P< 0.01). The reconstructed Kaplan Meier showed that ALI > 25 was significantly associated with a 56% reduction in the incidence of all-cause mortality compared with ALI ≤ 25 (HR 0.44, 95% CI 0.38-0.50, P< 0.000001). Conclusion: Among patients with HF, a low ALI was associated with a higher incidence of all-cause mortality rate than those with a high ALI. These findings suggest that ALI can be used for prognostic stratification and aid clinical decision-making in HF management.

Refractory angina affects patients’ quality of life around the world. Coronary sinus reducer (CSR) is a new therapeutic approach that has been investigated in recent years. We aimed to investigate the efficacy and safety of CSR for refractory angina. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) from PubMed, Web of Science, Scopus, Embase, and CENTRAL searches until May 2024. Dichotomous data were pooled using risk ratio (RR), and continuous data were pooled using mean difference (MD), both with a 95% confidence interval (CI), using (R version 4.3). With the inclusion of three RCTs, our cohort comprised a total of 180 patients. Compared with the control group, after 6 months, CSR was significantly associated with a decreased mean change of Canadian Cardiovascular Society (CCS) class [MD: −0.54 with 95% CI (−0.80 to −0.27), P < 0.01], a decreased number of patients in the CCS class III/IV [RR: 0.56 with 95% CI (0.38–0.84), P < 0.01], and increased exercise time [MD: 50.46 with 95% CI (9.47–91.45), P = 0.02]. However, there was no significant difference between CSR and the control group in double products, all Seattle Angina Questionnaire domains, and safety outcomes. CSR has been shown to reduce angina severity by lowering CCS class scores and increasing exercise time. Large-scale RCTs are needed to confirm its effectiveness in patients with refractory angina.

Abstract Background Since pulsed-field ablation (PFA) specifically targets myocardial tissue, it has become a cutting-edge substitute for radiofrequency (RF) and cryoablation. Purpose We aim to compare the safety and efficacy of PFA vs thermal ablation for AF ablation. Methods We conducted a systematic review and meta-analysis synthesizing randomized controlled trials (RCTs) and observational comparative studies, which were retrieved by systematically searching: PubMed, EMBASE, Web of Science, SCOPUS, and Cochrane through September 2023. RevMan version 5.4 software was used to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). Results Seventeen studies with a total of 2,255 patients were included. PFA was significantly associated with a decreased AF recurrence (RR: 0.65, 95% CI [0.51, 0.84], P= 0.0010) but not any arrhythmia recurrence (RR: 0.87, 95% CI [0.69, 1.09], P= 0.22). Also, PFA was significantly associated with decreased total procedure time (MD: -15.15, 95% CI [-20.23, -10.07], P&lt; 0.00001) and heart rate (MD: -7.56, 95% CI [-12.78, -2.34], P= 0.005); however, there was no significant difference between PFA and thermal ablation in fluoroscopy time (MD: 2.83, 95% CI [-0.38, 6.04], P= 0.08). PFA decreased phrenic nerve palsy (RR: 0.38, 95% CI [0.15, 0.98], P= 0.05) and esophageal lesions (RR: 0.09, 95% CI [0.01, 0.69], P= 0.02); however, PFA was significantly associated with increased pericardial tamponade (RR: 6.14 with 95% CI [1.43, 26.33], P= 0.01). Conclusion PFA was significantly associated with decreased AF recurrence, heart rate, total procedure time, phrenic nerve palsy, esophageal lesion, and increased incidence of pericardial tamponade compared with thermal ablation. However, current evidence is mainly weighted by observational studies, requiring further large-scale randomized trials.Figure

Abstract Background Left Ventricular Assist Devices (LVADs) and heart transplantation stand out as the two well-established and effective therapeutic approaches for managing patients with advanced heart failure. Exercise-based cardiac rehabilitation (EBCR) has been demonstrated to improve functional capacity in patients with LVAD. Purpose We aim to assess the efficacy and safety of EBCR in patients with LVAD. Also, to compare high-intensity (HIT) versus moderate-intensity (MIT) EBCR regimens in patients with LVAD. Methods A systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) studies obtained from PubMed, Embase Cochrane, Scopus, and WOS until January 2024. We used the fixed-effects model to report dichotomous outcomes using risk ratio (RR) and continuous outcomes using standardized mean difference (SMD) with a 95% confidence interval (CI). Results Six RCTs with 160 patients were included. There was no significant difference between EBCR and standard care regarding peak VO2 change [SMD: 0.24 with 95% CI (-0.14, 0.62), P= 0.21] and six-minute walk distance (6-MWD) change [SMD: 0.28 with 95% CI (-0.11, 0.66), P= 0.16]. Also, there was no significant difference between HIT and MIT exercise regarding peak VO2 change [SMD: 0.20 with 95% CI (-0.41, 0.82), P= 0.52] and 6-MWD change [SMD: 0.07 with 95% CI (-0.54, 0.69), P= 0.81]. Moreover, EBCR was associated with a significant decrease in the incidence of any adverse events when compared to usual care with [RR: 0.80 with 95% CI (0.65, 0.99), P= 0.04], while there was no significant difference between HIT and MIT exercise regarding the incidence of any adverse events [RR: 0.38 with 95% CI (0.02, 9.22), P= 0.55]. Conclusion EBCR did not improve functional capacity in patients with LVAD, with no significant effect on peak VO2 or 6-MWD.