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Testing of CYP2C19 Variants and Platelet Reactivity for Guiding Antiplatelet Treatment [Internet]

This comparative effectiveness review evaluated the analytic validity, prognostic value, and comparative effectiveness of two types of medical tests (genetic testing for CYP2C19 variants and phenotypic testing to measure platelet reactivity) to identify patients who are most likely to benefit from clopidogrel-based antiplatelet therapy and to guide antiplatelet therapy in patient populations who are eligible to receive or are already receiving clopidogrel treatment.

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: September 2013
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Stroke: National Clinical Guideline for Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA)

This guideline covers interventions in the acute stage of a stroke (‘acute stroke’) or transient ischaemic attack (TIA). Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions of up to 2 weeks are covered as well. This guideline is a stand-alone document, but is designed to be read alongside the Intercollegiate Stroke Working Party guideline ‘National clinical guideline for stroke’ which considers evidence for interventions from the acute stage into rehabilitation and life after stroke. The Intercollegiate Stroke Working Party guideline is an update of the 2004 2nd edition and includes all the recommendations contained within this guideline. This acute stroke and TIA guideline is also designed to be read alongside the Department of Health’s (DH) ‘National stroke strategy’ (NSS). Where there are differences between the recommendations made within this acute stroke and TIA guideline and the NSS, the Guideline Development Group (GDG) members feel that their recommendations are derived from systematic methodology to identify all of the relevant literature.

NICE Clinical Guidelines - National Collaborating Centre for Chronic Conditions (UK).

Version: 2008
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Drug Class Review: Beta Adrenergic Blockers: Final Report Update 4 [Internet]

Beta blockers inhibit the chronotropic, inotropic, and vasoconstrictor responses to the catecholamines, epinephrine, and norepinephrine. Beta blockers differ in their duration of effect (3 hours to 22 hours), the types of beta receptors they block (β1-selective or β1/β2-nonselective), whether they are simultaneously capable of exerting low level heart rate increases (intrinsic sympathomimetic activity [ISA]), and in whether they provide additional blood vessel dilation effects by also blocking alpha-1 receptors. All beta blockers are approved for the treatment of hypertension. Other US Food and Drug Administration-approved uses are specific to each beta blocker and include stable and unstable angina, atrial arrhythmias, bleeding esophageal varices, coronary artery disease, asymptomatic and symptomatic heart failure, migraine, and secondary prevention of post-myocardial infarction. The objective of this review was to evaluate the comparative effectiveness and harms of beta blockers in adult patients with hypertension, angina, coronary artery bypass graft, recent myocardial infarction, heart failure, atrial arrhythmia, migraine or bleeding esophageal varices.

Drug Class Reviews - Oregon Health & Science University.

Version: July 2009
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Enhancements to angioplasty for peripheral arterial occlusive disease: systematic review, cost-effectiveness assessment and expected value of information analysis

This study found that there is evidence of a significant clinical benefit, in terms of reducing restenosis rates, for self-expanding stents, stent graft, endovascular brachytherapy and drug-coated balloons compared with percutaneous transluminal balloon angioplasty and for drug-eluting stents compared with bare-metal stents. If it is assumed that patency translates into beneficial long-term clinical outcomes, then drug-coated balloons and bail-out drug-eluting stents are the enhancements to percutaneous transluminal balloon angioplasty that are most likely to be cost-effective.

Health Technology Assessment - NIHR Journals Library.

Version: February 2014
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The prognostic utility of tests of platelet function for the detection of ‘aspirin resistance’ in patients with established cardiovascular or cerebrovascular disease: a systematic review and economic evaluation

People with heart disease are often prescribed aspirin. Testing the function of platelets in the blood may be able to assess if aspirin is working properly. This review assessed all the evidence on the results of platelet function testing linked to the risk of having another cardiovascular event (such as a heart attack or stroke). The review found that people classified as ‘aspirin resistant’ by platelet function testing were, on average, slightly more at risk of having another cardiovascular event. However, the increase in risk was very small and it was not certain which was the most accurate of the platelet function tests available. Therefore, at the moment, the result of platelet function testing on its own is not very informative in determining a person’s future risk of cardiovascular events.

Health Technology Assessment - NIHR Journals Library.

Version: May 2015
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Engagement in research: an innovative three-stage review of the benefits for health-care performance

Study found that when clinicians and health-care organisations engage in research there is the likelihood of a positive impact on health-care performance. Many mechanisms are at work, often more than one in the same situation, but the evidence available for each is limited. Organisations that have deliberately integrated the research function into organisational structures demonstrate how research engagement can, among other factors, contribute to improved health-care performance.

Health Services and Delivery Research - NIHR Journals Library.

Version: October 2013
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MI - Secondary Prevention: Secondary Prevention in Primary and Secondary Care for Patients Following a Myocardial Infarction: Partial Update of NICE CG48 [Internet]

Myocardial infarction (MI) remains one of the most dramatic presentations of coronary artery disease (CAD). Complete occlusion of the artery often produces myocardial necrosis and the classical picture of a heart attack with severe chest pain, electrocardiographic (ECG) changes of ST-segment elevation, and an elevated concentration of myocardial specific proteins in the circulation. Such people are described as having a ST-segment elevation myocardial infarction (STEMI). Intermittent or partial occlusion produces similar, but often less severe clinical features, although no or transient and undetected ST elevation. Such cases are described as a non-ST segment elevation myocardial infarction (NSTEMI). People who have suffered from either of these conditions are amenable to treatment to reduce the risk of further MI or other manifestations of vascular disease, secondary prevention.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: November 2013
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Unstable Angina and NSTEMI: The Early Management of Unstable Angina and Non-ST-Segment-Elevation Myocardial Infarction

The development of cholesterol-rich plaque within the walls of coronary arteries (atherosclerosis) is the pathological process which underlies ‘coronary artery disease’. However, the clinical manifestations of this generic condition are varied. When the atherosclerotic process advances insidiously the lumen of a coronary artery becomes progressively narrowed blood supply to the myocardium is compromised (ischaemia) and the affected individual will often develop predictable exertional chest discomfort, or ‘stable’ angina. However, at any stage in the development of atherosclerosis, and often when the coronary artery lumen is narrowed only slightly or not at all, an unstable plaque may develop a tear of its inner lining cell layer (intima), exposing the underlying cholesterol rich atheroma within the vessel wall to the blood flowing in the lumen. This exposure stimulates platelet aggregation and subsequent clot (thrombus) formation.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: 2010
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Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Hospital

Venous thromboembolism (VTE) is a term used to include the formation of a blood clot (a thrombus) in a vein which may dislodge from its site of origin to travel in the blood, a phenomenon called embolism. A thrombus most commonly occurs in the deep veins of the legs; this is called deep vein thrombosis. A dislodged thrombus that travels to the lungs is known as a pulmonary embolism.

NICE Clinical Guidelines - National Clinical Guideline Centre – Acute and Chronic Conditions (UK).

Version: 2010
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Prophylaxis Against Infective Endocarditis: Antimicrobial Prophylaxis Against Infective Endocarditis in Adults and Children Undergoing Interventional Procedures [Internet]

Infective endocarditis (IE) is a rare condition with significant morbidity and mortality. It may arise following bacteraemia in a patient with a predisposing cardiac lesion. In an attempt to prevent this disease, over the past 50 years, at-risk patients have been given antibiotic prophylaxis before dental and certain non-dental interventional procedures.

NICE Clinical Guidelines - National Institute for Health and Clinical Excellence (UK).

Version: March 2008
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Efficacy of intrapleural instillation of fibrinolytics for treating pleural empyema and parapneumonic effusion: a meta-analysis of randomized control trials

INTRODUCTION: The effects of intrapleural fibrinolysis for treating pleural empyema and parapneumonic effusion remain uncertain.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

Cangrelor for patients undergoing percutaneous coronary intervention: evidence from a meta-analysis of randomized trials

Cangrelor is a new parenteral adenosine diphosphate P2Y12 receptor inhibitor with rapid, profound and reversible inhibition of platelet activity. The aim of this meta-analysis was to evaluate efficacy and safety of this new agent in patients undergoing percutaneous coronary intervention (PCI). We searched PubMed, Cochrane Library, EMBASE, Web of Science and CINAHL databases from the inception through April 2013. Randomized controlled trials (RCTs) comparing cangrelor with control (clopidogrel/placebo) were selected. We used the random-effects models to calculate the risk ratio. The primary efficacy outcome was risk of myocardial infarction, and the primary safety outcome was TIMI major bleeding at 48 h. Three RCTs included a total of 25,107 participants. Effects of Cangrelor were not different against comparators for myocardial infarction (MI) (Risk ratio [RR] 0.94, 95% confidence interval [CI] 0.78-1.13) and all-cause mortality (RR 0.72, 95% CI 0.36-1.43). However, cangrelor significantly reduced the risk of ischemia-driven revascularization (RR 0.72, 95% CI 0.52-0.98), stent thrombosis (RR 0.60, 95% CI 0.44-0.82) and Q wave MI (RR 0.53, 95% CI 0.30-0.92) without causing extra major bleeding (Thrombolysis in Myocardial infarction criteria) and severe or life-threatening bleeding (Global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries criteria). Separate analysis against only clopidogrel also showed similar findings except Q wave MI outcome. Use of cangrelor during PCI might reduce the risk of ischemia-driven revascularization and stent thrombosis, without causing extra major bleeding.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

Meta-analysis of randomized trials comparing enoxaparin versus unfractionated heparin as adjunctive therapy to fibrinolysis in ST-elevation acute myocardial infarction

This review assessed the effect of using enoxaparin, a low molecular weight heparin, as an additional therapy with fibrinolytic treatment (such as streptokinase) in people with ST-segment elevation acute myocardial infarction. The authors concluded that enoxaparin was more effective than unfractionated heparin. However, the rates of major bleeding when using enoxaparin were significant.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2003

Efficacy of thrombolytic agents in the treatment of pulmonary embolism

This review assessed the use of alteplase, given as an infusion or a bolus injection, and streptokinase for the treatment of pulmonary embolism. The authors concluded that firm recommendations as to which thrombolytic regimen is preferable cannot be drawn from the insufficient evidence found; further research is needed. This conclusion is appropriate given the data presented.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2005

Adjunctive benefits from low-molecular-weight heparins as compared to unfractionated heparin among patients with ST-segment elevation myocardial infarction treated with thrombolysis: a meta-analysis of the randomized trials

This review found that low molecular weight heparins are associated with a reduction in reinfarction and a trend towards reduced mortality, but with a higher risk of major bleeding complications, compared with unfractionated heparin. These conclusions are likely to be reliable, but should be interpreted with some degree of caution given the failure to assess the validity of the included studies.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2007

Local treatment of empyema in children: a systematic review of randomized controlled trials

The review concluded there was little evidence that intrapleural fibrinolysis was more effective than saline and no evidence that it was more effective than video-assisted thoracoscopic surgery in treating complicated parapneumonic effusions or empyema in children. These conclusions appear likely to be reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2010

Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques

This review concluded that catheter-directed therapy was a relatively safe and effective alternative treatment for acute massive pulmonary embolism. Given that the appropriateness of pooling was unclear and that study quality was not assessed, the authors' conclusions may not be reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2009

Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials

This review concluded that evidence for a benefit of thrombolytic therapy compared with heparin for the initial treatment of patients with acute pulmonary embolism was lacking; there may be a benefit in high-risk patients. Given the limitations of the evidence available, the reliability and applicability of the overall estimates and conclusions are uncertain.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2004

Transferring patients with ST-segment elevation myocardial infarction for mechanical reperfusion: a meta-regression analysis of randomized trials

The authors concluded that among patients with ST-segment elevation myocardial infarction, transfer for mechanical perfusion reduced 30-day mortality, infarction and stroke rates. This review was generally well-conducted and these conclusions appear reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2008

Intravenous glycoprotein IIb/IIIa receptor antagonists reduce mortality after percutaneous coronary interventions

This review evaluated the impact of intravenous platelet glycoprotein IIb/IIIa receptor antagonists on mortality in patients undergoing percutaneous coronary intervention. Glycoprotein IIb/IIIa receptor antagonists were found to confer a significant and sustained decrease in the risk of death. Although full details of the methods of the review were not given, the conclusions are supported by the evidence presented.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2003

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